Indoor Air Quality Medical Questionnaire

ICR 199701-2105-001

OMB: 2105-0533

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
25098
Migrated
ICR Details
2105-0533 199701-2105-001
Historical Active 199611-2105-001
DOT/OST
Indoor Air Quality Medical Questionnaire
Revision of a currently approved collection   No
Regular
Approved without change 02/11/1997
Retrieve Notice of Action (NOA) 01/31/1997
  Inventory as of this Action Requested Previously Approved
02/29/2000 02/29/2000 05/31/1997
5,500 0 5,500
1,500 0 1,500
0 0 0

Survey to canvass employees within DOT headquarters building to collect pertinent information regarding environmental and health problems to aid in resolving any problems identified.

None
None


No

1
IC Title Form No. Form Name
Indoor Air Quality Medical Questionnaire

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 5,500 5,500 0 0 0 0
Annual Time Burden (Hours) 1,500 1,500 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
01/31/1997


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