Information Collection

Hazardous Conditions Complaints

IC 14363 under ICR 201910-1219-001 · OMB 1219-0014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0014 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
1219-0014 Hazardous Condition Complaint MSHA INTRO.pdf www.msha.gov/support-resources/forms-online-filing/2018/05/23/hazardous-condition-complaint	Instruction
Hazardous Conditions Compliant (ENGLISH) 1219-0014 Screen Shots Web Instrument.docx www.msha.gov/support-resources/forms-online-filing/2018/05/23/hazardous-condition-complaint	Form and Instruction
Hazardous Conditions Complaint (SPANISH) 1219-0014 Screen Shots Web Instrument SPANISH.docx www.msha.gov/support-resources/forms-online-filing/2018/05/23/hazardous-condition-complaint	Form and Instruction

IC Title:

Hazardous Conditions Complaints

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 30 CFR 43.4 30 CFR 43.7

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
Instruction			1219-0014 Hazardous Condition Complaint MSHA INTRO.pdf	https://www.msha.gov/support-resources/forms-online-filing/2018/05/23/hazardous-condition-complaint	Yes	Yes	Fillable Fileable
Form and Instruction	None	Hazardous Conditions Complaint (SPANISH)	1219-0014 Screen Shots Web Instrument SPANISH.docx	https://www.msha.gov/support-resources/forms-online-filing/2018/05/23/hazardous-condition-complaint	Yes	Yes	Fillable Fileable
Form and Instruction	None	Hazardous Conditions Compliant (ENGLISH)	1219-0014 Screen Shots Web Instrument.docx	https://www.msha.gov/support-resources/forms-online-filing/2018/05/23/hazardous-condition-complaint	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,976

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 96 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,976	-535	2,511
Annual IC Time Burden (Hours)	395	-107	502
Annual IC Cost Burden (Dollars)	0	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.