Information Collection

Employment Questionnaire

IC 28228 under ICR 200004-2900-003 · OMB 2900-0079.

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Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Employment Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	21-4140-1	No	No
Form	21-4140	No	No
Form	21-4140A	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45,480

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	45,480	45,480
Annual IC Time Burden (Hours)	3,790	3,790
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.