Exposure Assessment Questionnaire

Exposure Assessment and Epidemiological Study of U.S. Workers Exposed to Carbon Nanotubes and Nanofibers

Documents and Forms

Document Name Document Type
Exposure Assessment Questionnaire Form
Questionnaire Attachment C-1-questionnaire.docx Form
Attachment C-2-Exposure factors.docx Exposure Factors IC Document

Information Collection (IC) Details

IC Title:	Exposure Assessment Questionnaire	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
Form	none	Questionnaire	Attachment C-1-questionnaire.docx		Yes	No	Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies and EEOICPA Records	FR Citation: 76 FR 34706

Number of Respondents: 33	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	33	33
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Exposure Factors	Attachment C-2-Exposure factors.docx	02/28/2013

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