Health Hazard Evaluation Request Form for Employees and Employers

Health Hazard Evaluations/Technical Assistance and Emerging Problems

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.