Information Collection

Annual Questionnaire

IC 213739 under ICR 201411-0920-002 · OMB 0920-1057.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Annual Questionnaire	Form
Annual Questionnaire Attch I-1 - Annual Questionnaire_2014_10_17.docx	Form
Annual Questionnaire - Spanish Attch. I-2 - Annual Questionnaire-Spanish_2014_10_17.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Annual Questionnaire	Attch I-1 - Annual Questionnaire_2014_10_17.docx		No		Paper Only
Form	none	Annual Questionnaire - Spanish	Attch. I-2 - Annual Questionnaire-Spanish_2014_10_17.docx		No		Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: Occupational Health Epidemiological Studies and EEOICPA Program Records

FR Citation: 76 FR 34706

Number of Respondents: 960

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	960	960
Annual IC Time Burden (Hours)	480	480
Annual IC Cost Burden (Dollars)	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.