Information Collection

Personal Air Sampling _ Contact Information Form

IC 210760 under ICR 201403-0920-006 · OMB 0920-1024.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att J_Personal Air Sampling -Contact Info Form.docx	Other-WORD
Att K_Personal Air Sampling Log.docx Att K_Personal Air Sampling Log	IC Document
Att L_Results letter for personal air sampling.docx Att L_Results letter for personal air sampling	IC Document

IC Title:

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 J_Personal Air Sampling -Contact Info Form.docx		No	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records, HHS/CDC/NIOSH

FR Citation: 76 FR 34706

Number of Respondents: 95

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	95	95
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att K_Personal Air Sampling Log	Att K_Personal Air Sampling Log.docx	03/11/2014
Att L_Results letter for personal air sampling	Att L_Results letter for personal air sampling.docx	03/11/2014

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