Information Collection

Respiratory Health of Healthcare Workers and Blood Donor History Questionnaires

IC 200032 under ICR 201002-0920-006 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Respiratory Health of Healthcare Workers and Blood Donor History Questionnaires	Form and Instruction
Survey on Respiratory Health QDRL NIOSH Resp Health Attach1.doc	Form and Instruction
Blood Donor History Questionnaire QDRL OASH Blood Donor Attach 1.doc	Form and Instruction
QDRL OMB-10-day combo letter.doc Letter to Dr. Schwab	IC Document
QDRL NIOSH Resp Health Attach2.docx Respiratory - Att 2 Flyer	IC Document
QDRL NIOSH Resp Health 10-day letter.doc Respiratory - Letter to OMB	IC Document
QDRL OASH Blood Donor Attach 2abc.docx Blood Donor - Att 2a Flyer	IC Document
QDRL OASH Blood Donor 10-day letter-fnl.doc Blood Donor - Letter to OMB	IC Document

IC Title:

Respiratory Health of Healthcare Workers and Blood Donor History Questionnaires

Agency IC Tracking Number:

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
Form and Instruction	none	Survey on Respiratory Health	QDRL NIOSH Resp Health Attach1.doc		No	No	Paper Only
Form and Instruction	none	Blood Donor History Questionnaire	QDRL OASH Blood Donor Attach 1.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Health and Demographic Surveys Conducted in Probablity Samples of the US Population

FR Citation: 49 FR 37693

Number of Respondents: 125

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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	125	0	0	0	0	0
Annual IC Time Burden (Hours)	125	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter to Dr. Schwab	QDRL OMB-10-day combo letter.doc	10/31/2011
Respiratory - Att 2 Flyer	QDRL NIOSH Resp Health Attach2.docx	10/31/2011
Respiratory - Letter to OMB	QDRL NIOSH Resp Health 10-day letter.doc	10/31/2011
Blood Donor - Att 2a Flyer	QDRL OASH Blood Donor Attach 2abc.docx	10/31/2011
Blood Donor - Letter to OMB	QDRL OASH Blood Donor 10-day letter-fnl.doc	10/31/2011

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