Information Collection

Pulmonary Health Questionnaire

IC 6933 under ICR 200903-0920-007 · OMB 0920-0494.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att.3_Pulmonary Health Questionnaire_020509.doc.rtf	Other-WORD
Attachment 5 12-12-08.doc Consent Form	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.9 5 CFR 1328.8(b)(3)

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			Att.3_Pulmonary Health Questionnaire_020509.doc.rtf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form	Attachment 5 12-12-08.doc	02/17/2009

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