Information Collection

Att D_Sample HHE Specific Worker Interview

IC 185719 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0920-0260 Att D_Sample HHE Specific Worker Interview Form
0920-0260 HHE Specific Worker Interview - example Attachment D.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att D_Sample HHE Specific Worker Interview	Agency IC Tracking Number:	0920-0260

Is this a Common Form? No		IC Status: Modified

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	0920-0260	HHE Specific Worker Interview - example	Attachment D.docx		No		Paper Only

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: 1,470	Number of Respondents for Small Entity: 1,200

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,470	-1,110	2,580
Annual IC Time Burden (Hours)	368	-277	645
Annual IC Cost Burden (Dollars)	12,554	-9,479	22,033

Documents for IC

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