Form B 42 CFR Part 83.9

EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0639 can be found here:

Documents and Forms

Document Name Document Type
Attachment D2 Example of Petition without Form B.rev 1.pdf Instruction
Attachment D1 SEC Form B Instructions.rev 2.pdf Attachment D1 Form B instructions IC Document

Information Collection (IC) Details

IC Title:	Form B 42 CFR Part 83.9	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attachment D2 Example of Petition without Form B.rev 1.pdf		Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program	FR Citation: 68 FR 55962

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D1 Form B instructions	Attachment D1 SEC Form B Instructions.rev 2.pdf	07/14/2010

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