Information Collection

Health questionnaire

IC 183661 under ICR 200802-0920-002 · OMB 0920-0784.

Documents and Forms

Document Name Document Type
Attachment 5 Health questionnaire.doc Other-health questionnaire

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health 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-health questionnaire			Attachment 5 Health questionnaire.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 0920-0147: Occupational Health Epidemiological Studies and EEOICPA Program Records	FR Citation: 51 FR 42449

Number of Respondents: 140	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	12	12
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.