Information Collection

NIOSH-Administered Questionnaire

IC 185268 under ICR 200806-0920-003 · OMB 0920-0793.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix_H.doc	Other-WORD
Appendix_F.doc Study Announcement	IC Document

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-WORD			Appendix_H.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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	300	300
Annual IC Time Burden (Hours)	225	225
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Study Announcement	Appendix_F.doc	05/29/2008

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