Noa 0920-0260

Attachment A: HHE local health department survey, NOA 0920-0260

NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date 11/17/2011
Department of Health and Human Services
Centers for Disease Control and Prevention
FOR CERTIFYING OFFICIAL: Michael Carleton
FOR CLEARANCE OFFICER: Mary Forbes
In accordance with the Paperwork Reduction Act, OMB has taken action on your request received
09/27/2011
ACTION REQUESTED: Revision of a currently approved collection
TYPE OF REVIEW REQUESTED: Regular
ICR REFERENCE NUMBER: 201109-0920-006
AGENCY ICR TRACKING NUMBER:
TITLE: Health Hazard Evaluations/Technical Assistance and Emerging Problems
LIST OF INFORMATION COLLECTIONS: See next page
OMB ACTION: Approved without change
OMB CONTROL NUMBER: 0920-0260
The agency is required to display the OMB Control Number and inform respondents of its legal significance in
accordance with 5 CFR 1320.5(b).
EXPIRATION DATE: 11/30/2014

DISCONTINUE DATE:

BURDEN:

RESPONSES

HOURS

COSTS

11,690

4,007

0

8,160

2,874

0

0

0

0

-3,530

-1,133

0

Change due to Agency Adjustment

0

0

0

Change Due to Potential Violation of the PRA

0

0

0

Previous
New
Difference
Change due to New Statute
Change due to Agency Discretion

TERMS OF CLEARANCE: Previous terms of clearance continue: Approved consistent with the following
terms of clearance: approved for purposes of conducting investigations/evaluations, given the anecdotal
nature of gathered data information obtained through these collections of information will not be used to
develop estimates related to health or safety risks in general.
OMB Authorizing Official:

Kevin F. Neyland
Deputy Administrator,
Office Of Information And Regulatory Affairs

Attachment A: HHE local health department survey, NOA 0920-0260

List of ICs
IC Title
Health Hazard Evaluation
Specific Questionnaire
(Example)
Health Hazard Evaluation
Request Form for
Employees and Employers
Health Hazard Evaluation
Specific Interview
(Example)
Initial and Follow-back for
Onsite Evaluations Year 1
Follow-back without
Onsite Evaluation Year 1
Follow-back without
Onsite Evaluation Year 2
Followback for Onsite
Evaluations Year 2
Followback for Onsite
Evaluations Year 1

Form No.

Form Name

none

HHE Evaluation

none

HHE Request Form

none

HHE Evaluation Ineview

none
none
none
none
none

HHE Initial and
Follow-back
Followback no onsite
Year 1
Follow-back no onsite
Year 2
Followback Year 2
Followback Year 1

CFR Citation