Personal Air Sampling _ Contact Information Form

An Investigation of Lung Health at an Indium-Tin Oxide Production Facility

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Personal Air Sampling _ Contact Information Form	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
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 %

	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

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.