Information Collection

Health Screening Consent / Contact Form

IC 202693 under ICR 201206-0920-002 · OMB 0920-0965.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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 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 %

table that charts list of burden
	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

table that charts IC Documents
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.