Information Collection

Health Hazard Evaluation Request Form for Employees and Employers

IC 185718 under ICR 201408-0920-011 · OMB 0920-0260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0260 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Health Hazard Evaluation Request Form for Employees and Employers	Form
HHE Request Form for employees and employers Attachment C.doc	Form
HHE Request form Attch C1 - 11.13.14.pdf	Form

IC Title:

Health Hazard Evaluation Request Form for Employees and Employers

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	HHE Request Form for employees and employers	Attachment C.doc		Yes	Yes	Fillable Fileable
Form	none	HHE Request form	Attch C1 - 11.13.14.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Occupational Health Epidemiological Studies

FR Citation: 76 FR 34706

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	300	-20	320
Annual IC Time Burden (Hours)	60	-4	64
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.