Signed Consent Forms for Medical Exams

Chronic Beryllium Disease Prevention Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1910-5112 can be found here:

Documents and Forms

Document Name Document Type
Form DOE F 440-1 Signed Consent Forms for Medical Exams Form and Instruction
DOE F 440-1 Chronic Beryllium Disease Prevention Program Informed Co 1910-5112 Instrument DOE F 440.1.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Signed Consent Forms for Medical Exams	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 850

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DOE F 440-1	Chronic Beryllium Disease Prevention Program Informed Consent	1910-5112 Instrument DOE F 440.1.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,976	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,982	1,498	4,484
Annual IC Time Burden (Hours)	1,496	375	1,121
Annual IC Cost Burden (Dollars)	191,826	76,083	115,743

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.