Pulmonary Health Questionnaire

Exposure to Aerosolized Brevetoxins During Red Tide Events

Documents and Forms

Document Name Document Type
Att.3_Pulmonary Health Questionnaire_020509.doc.rtf Other-WORD
Attachment 5 12-12-08.doc Consent Form IC Document

Information Collection (IC) Details

IC Title:	Pulmonary Health Questionnaire	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:

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 %

	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

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.