Information Collection

Att H_ Initial Site Visit Followback Survey Form

IC 185720 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⚠️ Notice: This information collection may be referencing outdated material.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 H_ Initial Site Visit Followback Survey Form	Form
0920-0260 Initial Site Visit Followback Survey Form Attachment_H.docx	Form

IC Title:

Att H_ Initial Site Visit Followback Survey Form

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	Initial Site Visit Followback Survey Form	Attachment_H.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: 140

Number of Respondents for Small Entity: 115

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	140	-104	244
Annual IC Time Burden (Hours)	23	-18	41
Annual IC Cost Burden (Dollars)	797	-591	1,388

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.