Information Collection Provisions in 42 CFR Part 84 - (Standard Application fro the Approval of Resiporators)

Form Approved: OMB No. 0920-0109
Exp. Date: XXX xx, 2oxx

Section C.1 : Project Reference Numbers
_I

What is your NIOSH-assigned Manufacturer Code?

0

Manufacturer holds a current approval

Assign a unique reference number to this application, as directed byNIOSH

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Section C.2: Type of Application
Type of Application:

ublic r eporting burden of this collection of information is estimated t o average 229 hours per response, including the time for
eviewing ins tructions, searching existing data sources, ga therin g and main taining the data needed, and completin g and
eviewing the collection of i nfor mation . An agency may not conduct or sponsor, a nd a person is not required to respond to a
~ollection of information unless it displays a cuiTentlyvalid OMB control number. S end commen ts regarding this burde n
festimate or any other aspect of this collection of informa tion, including suggestions for reducin g this burden to CDC/ATSDR
!Reports Clearance Officer, 1600 Clifton Road NE, MS D-7 4, Atlan ta, Georgia 30333: ATTN: PRA(0920-0 l09). Do not send the
ompl eted form to this address