Information Collection

Medical Surveillance - Periodic Questionnaire

IC 182439 under ICR 201101-2070-002 · OMB 2070-0072.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Medical Surveillance - Periodic Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 40 CFR 763, Subpart G (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Environmental Management

Subfunction: Pollution Prevention and Control

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,750	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,750	-282	3,032
Annual IC Time Burden (Hours)	458	-47	505
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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