Information Collection

Health Hazard Evaluation Request Form for Employees and Employers

IC 185718 under ICR 201708-0920-027 · OMB 0920-0260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0260 can be found here:

Documents and Forms

Document Name Document Type
Health Hazard Evaluation Request Form for Employees and Employers Form
HHE Request Form Attachment_C.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Hazard Evaluation Request Form for Employees and Employers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	HHE Request Form	Attachment_C.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies	FR Citation: 76 FR 34706

Number of Respondents: 290	Number of Respondents for Small Entity: 135

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	290	-10	300
Annual IC Time Burden (Hours)	58	-2	60
Annual IC Cost Burden (Dollars)	1,981	1,981	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.