Information Collection

Assessment of Occupational Exposure Management

IC 180121 under ICR 200705-0920-005 · OMB 0920-0757.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Assessment of Occupational Exposure Management	Form and Instruction
Ambulatory Care Facilities Attachment D. CDC_AMB_final.pdf	Form and Instruction
Long-term Care Facilities Attachment E. CDC_LTC_final.pdf	Form and Instruction
Acute Care Facilities Attachment C. CDC_ACC_final.pdf	Form and Instruction
Dialysis Centers Attachment F. CDC_DIAL_final.pdf	Form and Instruction
Attach B invitation_prenot_rev050207.doc Pre-notification Letter	IC Document
Attach G first_cover_rev05022007.doc First Cover Letter to Respondents	IC Document
Attach H second_cover_rev05022007.doc Second Cover Letter to Respondents	IC Document
Attachment I. AMB_Screen shots.pdf Example Screen Shots for Ambulatory CCs	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Ambulatory Care Facilities	Attachment D. CDC_AMB_final.pdf	Yes	Yes	Fillable Printable
Form and Instruction	None	Long-term Care Facilities	Attachment E. CDC_LTC_final.pdf	Yes	Yes	Fillable Printable
Form and Instruction	None	Acute Care Facilities	Attachment C. CDC_ACC_final.pdf	Yes	Yes	Fillable Printable
Form and Instruction	None	Dialysis Centers	Attachment F. CDC_DIAL_final.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,320

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,320	5,320
Annual IC Time Burden (Hours)	1,773	1,773
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Pre-notification Letter	Attach B invitation_prenot_rev050207.doc	05/02/2007
First Cover Letter to Respondents	Attach G first_cover_rev05022007.doc	05/02/2007
Second Cover Letter to Respondents	Attach H second_cover_rev05022007.doc	05/02/2007
Example Screen Shots for Ambulatory CCs	Attachment I. AMB_Screen shots.pdf	05/02/2007

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