Information Collection

Hazardous Substances Emergency Events Surveillance Data Request Form

IC 184375 under ICR 200804-0923-001 · OMB 0923-0008.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
appendix 3a - DataRequestForm2005.pdf	Other-data request form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 103

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-data request form			appendix 3a - DataRequestForm2005.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	50	50
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.