Information Collection

Initial Participants (Health Questionnaire) Phase 2

IC 196087 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Att 4-health questionnaire_Influenza 11 15 10.docx Other-WORD
Att 3-flyer_Influenza 11 15 10.docx Att 3-flyer_Influenza 11 15 10 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Initial Participants (Health Questionnaire) Phase 2	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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 4-health questionnaire_Influenza 11 15 10.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0147 " Occupational Health Epidemiological Studies and EEOICPA Program Records"	FR Citation: 51 FR 226

Number of Respondents: 44	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-44	44
Annual IC Time Burden (Hours)	-4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 3-flyer_Influenza 11 15 10	Att 3-flyer_Influenza 11 15 10.docx	12/20/2010

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