Information Collection

Health questionnaire

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 5 Health questionnaire.doc	Other-health questionnaire

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-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 %

table that charts list of burden
	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

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.