Health Screening Consent / Contact Form

National Healthy Worksite Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0965 can be found here:

Documents and Forms

Document Name Document Type
Att G-1_EmpConsContForm.pdf Other-WORD
Att F-2_Employee Health Assessment.pdf Other-word
Att G-2 HIPAA Privacy Practices.pdf Att G-2 HIPAA Privacy Practices IC Document
Att G-3 PhysRefForm (1).pdf Att G-3 PhysRefForm (1) IC Document
Att G-4 Understand HlthScrRes.pdf Att G-4 Understand HlthScrRes IC Document
Att G-5 NHWP FAQs.pdf Att G-5 NHWP FAQs IC Document

Information Collection (IC) Details

IC Title:	Health Screening Consent / Contact Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-word			Att F-2_Employee Health Assessment.pdf		No		Paper Only
Other-WORD			Att G-1_EmpConsContForm.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	833	833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att G-2 HIPAA Privacy Practices	Att G-2 HIPAA Privacy Practices.pdf	06/04/2012
Att G-3 PhysRefForm (1)	Att G-3 PhysRefForm (1).pdf	06/04/2012
Att G-4 Understand HlthScrRes	Att G-4 Understand HlthScrRes.pdf	06/04/2012
Att G-5 NHWP FAQs	Att G-5 NHWP FAQs.pdf	06/04/2012

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