Appendix A

Access to Employee Exposure and Medical Records (29 CFR 1910.1020)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1218-0065 can be found here:

Documents and Forms

Document Name Document Type
Form Appendix A Appendix A Form
Appendix A Sample Authorization Letter for the Release of Employee Appendix A w burden box.pdf Form

Information Collection (IC) Details

IC Title:	Appendix A	Agency IC Tracking Number:	1218-0065(2017)

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1910.1020(e)(2)(ii)(B) 29 CFR 1910 Appendix A

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Appendix A	Sample Authorization Letter for the Release of Employee Medical Record Information to a Designated Representative (Non-Mandatory)	Appendix A w burden box.pdf		No		Printable Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,183	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,183	1,183
Annual IC Time Burden (Hours)	1,183	1,183
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.