Information Collection

Appendix A

IC 225683 under ICR 201911-1218-005 · OMB 1218-0065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1218-0065 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Appendix A Appendix A	Form
Appendix A Sample Authorization Letter for the Release of Employee Appendix A w burden box w OMB number moved to right side.pdf	Form

IC Title:

Appendix A

Agency IC Tracking Number:

1218-0065(2020)

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1910 Appendix A 29 CFR 1910.1020(e)(2)(ii)(B)

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	Appendix A	Sample Authorization Letter for the Release of Employee Medical Record Information to a Designated Representative (Non-Mandatory)	Appendix A w burden box w OMB number moved to right side.pdf		No		Printable Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,667

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,334	14,151	1,183
Annual IC Time Burden (Hours)	1,278	95	1,183
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.