Information Collection

Airborne Hazard and Open Burn Pit Registry Self-Assessment Questionnaire

IC 235161 under ICR 201903-2900-001 · OMB 2900-0800.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10066 Airborne Hazard and Open Burn Pit Registry Self-Assessment Questionnaire	Form and Instruction
10-10066 Airborne Hazards and Open Burn Pit Registry Self-Assessm VA Form 10-10066_Open Burn Pit Registry Self-Assessment Questionnaire_SW.._.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10066	Airborne Hazards and Open Burn Pit Registry Self-Assessment Questionnaire	VA Form 10-10066_Open Burn Pit Registry Self-Assessment Questionnaire_SW.._.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	33,333	33,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.