Information Collection

Medical and Work History Questionnaire

IC 182448 under ICR 200710-0920-009 · OMB 0920-0771.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
NIOSH DRDS Appendix B Prevent Be Disease Questionnaire.doc	Other-Computer Assisted Survey

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.