Information Collection

Activity 2 - Phlebotomist Safety Exclusion Questions Form - (Adult/Adolescent Facility Users)

IC 222465 under ICR 201608-0923-002 · OMB 0923-0054.

Documents and Forms

Document Name Document Type
Activity 2 - Phlebotomist Safety Exclusion Questions Form - (Adult/Adolescent Facility Users) Form and Instruction
Activity 2 - Phlebotomist Safety Exclusion Questions Att5g Phlebotomist Safety Exclusion Questions Form.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Activity 2 - Phlebotomist Safety Exclusion Questions Form - (Adult/Adolescent Facility Users)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 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: 27	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	27	27
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	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.