Health Record

Safety and Health Information Collection

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0693-0080 can be found here:

Documents and Forms

Document Name Document Type
Form NIST-986 Health Record Form
NIST-986 Health Record NIST-986 Health Record.docx Form

Information Collection (IC) Details

IC Title:	Health Record	Agency IC Tracking Number:	ER

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	NIST-986	Health Record	NIST-986 Health Record.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: COMMERCE/DEPT-18: Employees Personnel Files Not Covered by Notices of Other Agencies	FR Citation: 72 FR 6200

Number of Respondents: 333	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	333	333
Annual IC Time Burden (Hours)	56	56
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.