Information Collection

Activity 2 - Phlebotomist Safety Exclusion Questions Form (Parents/Guardians of Youth/Child Facility Users)

IC 222468 under ICR 201608-0923-001 · OMB 0923-0054.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0054 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Activity 2 - Phlebotomist Safety Exclusion Questions Form (Parents/Guardians of Youth/Child Facility Users)	Form and Instruction
Activity 2 - Phlebotomist Safety Exclusion Questions Att5g Phlebotomist Safety Exclusion Questions Form.docx	Form and Instruction

IC Title:

Activity 2 - Phlebotomist Safety Exclusion Questions Form (Parents/Guardians of Youth/Child Facility Users)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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 and Instruction	NA	Activity 2 - Phlebotomist Safety Exclusion Questions	Att5g Phlebotomist Safety Exclusion Questions Form.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-19-0001 Record of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 57 FR 62814

Number of Respondents: 18

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	1	1
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.