Information Collection

Phlebotomist Safety Exclusion Questions

IC 226777 under ICR 201705-0923-001 · OMB 0923-0058.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0058 can be found here:

Documents and Forms

Document Name Document Type
Phlebotomist Safety Exclusion Questions Form
Phlebotomist Safety Exclusion Questions Att4g Phlebotomist Safety Exclusion Questions Form_Final.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Phlebotomist Safety Exclusion Questions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	Phlebotomist Safety Exclusion Questions	Att4g Phlebotomist Safety Exclusion Questions Form_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Record of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 76 FR 4432

Number of Respondents: 27	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	27	27
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	6	6

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.