Information Collection

Health Questionnaire

IC 196082 under ICR 201405-0920-001 · OMB 0920-0888.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0888 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Health Questionnaire	Form
Health Questionnaire Attachment 5 - Health Questionnaire.docx	Form

IC Title:

Health Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form	none	Health Questionnaire	Attachment 5 - Health Questionnaire.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Occupational Health Epidemiological Studies and EEOICPA Records

FR Citation: 76 FR 34706

Number of Respondents: 180

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	Previously Approved
Annual Number of Responses for this IC	180	140	40
Annual IC Time Burden (Hours)	15	8	7
Annual IC Cost Burden (Dollars)	0	0	0

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.