Information Collection

Att C_Request for a Health Hazard Evaluation (Employees and Employers)

IC 185718 under ICR 202005-0920-003 · OMB 0920-0260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0260 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0260 Att C_Request for a Health Hazard Evaluation (Employees and Employers)	Form
Form 0920-0260 HHE Request Form Att C_Request for a Health Hazard Evaluation (Employees and Employers)	Form
0920-0260 HHE Request Form Att C_Hlth Haz Eval Req Form - English.pdf	Form
Att C1_Hlth Haz Eval Req Form - Spanish.docx Att C1_HHE Request Form (Spanish version)	IC Document

IC Title:

Att C_Request for a Health Hazard Evaluation (Employees and Employers)

Agency IC Tracking Number:

0920-0260

Is this a Common Form? No

IC Status: Modified

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	0920-0260	HHE Request Form	Att C_Hlth Haz Eval Req Form - English.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Occupational Health Epidemiological Studies

FR Citation: 76 FR 34706

Number of Respondents: 250

Number of Respondents for Small Entity: 135

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	250	-40	290
Annual IC Time Burden (Hours)	50	-8	58
Annual IC Cost Burden (Dollars)	1,708	-273	1,981

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att C1_HHE Request Form (Spanish version)	Att C1_Hlth Haz Eval Req Form - Spanish.docx	06/02/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.