Information Collection

EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)

IC 180183 under ICR 200705-0920-006 · OMB 0920-0639.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0639 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 83.9 EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)	Form
83.9 Special Exposure Cohort Petition Form B Attachment E - Instructions for Form B SEC.pdf	Form
Attachment E - Instructions for Form B SEC.pdf Instructions for Form B	IC Document

IC Title:

EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	83.9	Special Exposure Cohort Petition Form B	Attachment E - Instructions for Form B SEC.pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Instructions for Form B	Attachment E - Instructions for Form B SEC.pdf	05/04/2007

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