Information Collection

Initial Participants (Health Questionnaire) Phase 1

IC 196080 under ICR 201102-0920-002 · OMB 0920-0888.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0888 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 4-health questionnaire_Influenza 11 15 10.docx	Other-WORD
Att 3-flyer_Influenza 11 15 10.docx Att 3-flyer_Influenza 11 15 10	IC Document

IC Title:

Initial Participants (Health Questionnaire) Phase 1

Agency IC Tracking Number:

Is this a Common Form? No

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
Other-WORD			Att 4-health questionnaire_Influenza 11 15 10.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0147 " Occupational Health Epidemiological Studies and EEOICPA Program Records"

FR Citation: 51 FR 226

Number of Respondents: 44

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 Agency Discretion
Annual Number of Responses for this IC	44	44
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 3-flyer_Influenza 11 15 10	Att 3-flyer_Influenza 11 15 10.docx	12/20/2010

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