Medical and Work History Questionnaire

Long-Term Efficacy of a Program to Prevent Beryllium Disease

Documents and Forms

Document Name Document Type
NIOSH DRDS Appendix B Prevent Be Disease Questionnaire.doc Other-Computer Assisted Survey

Information Collection (IC) Details

IC Title:	Medical and Work History Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Computer Assisted Survey			NIOSH DRDS Appendix B Prevent Be Disease Questionnaire.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Medical and Laboratory Studies	FR Citation: 59 FR 42449

Number of Respondents: 193	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	193	193
Annual IC Time Burden (Hours)	145	145
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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