Health Hazard Evaluation Request Form for Employees and Employers

Health Hazard Evaluations/Technical Assistance and Emerging Problems

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0260 can be found here:

Documents and Forms

Document Name Document Type
Health Hazard Evaluation Request Form for Employees and Employers Form
HHE Request Form Attachment C.pdf Form
Attachment C- Spanish version.docx Spanish Version IC Document

Information Collection (IC) Details

IC Title:	Health Hazard Evaluation Request Form for Employees and Employers	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
Form	none	HHE Request Form	Attachment C.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies	FR Citation: 51 FR 42449

Number of Respondents: 320	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	320	-100	420
Annual IC Time Burden (Hours)	64	-20	84
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Spanish Version	Attachment C- Spanish version.docx	09/22/2011

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