Information Collection

Signed Consent Forms for Medical Exams

IC 45140 under ICR 201212-1910-002 · OMB 1910-5112.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1910-5112 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DOE F 440-1 Signed Consent Forms for Medical Exams	Form and Instruction
DOE F 440-1 Chronic Beryllium Disease Prevention Program Informed Co 1910-5112 Instrument DOE F 440.1.pdf	Form and Instruction

IC Title:

Signed Consent Forms for Medical Exams

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 850

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
Form and Instruction	DOE F 440-1	Chronic Beryllium Disease Prevention Program Informed Consent	1910-5112 Instrument DOE F 440.1.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,477

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
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,484	-1,446	5,930
Annual IC Time Burden (Hours)	1,121	-362	1,483
Annual IC Cost Burden (Dollars)	115,743	-27,975	143,718

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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