Form A 42 CFR 83.9

EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0639 can be found here:

Documents and Forms

Document Name Document Type
Attachment C SEC Form A.pdf Instruction

Information Collection (IC) Details

IC Title:	Form A 42 CFR 83.9	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 83

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attachment C SEC Form A.pdf		Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program records. HHS/CDC/NIOSH	FR Citation: 68 FR 55962

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5	-25	30
Annual IC Time Burden (Hours)	1	-1	2
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.