Information Collection

Att F_Sample HHE Specific Worker Questionnaire

IC 37747 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⚠️ Notice: This information collection may be referencing outdated material.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 F_Sample HHE Specific Worker Questionnaire Form and Instruction
0920-0260 Specific Worker Questionnaire - example Attachment F.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att F_Sample HHE Specific Worker Questionnaire	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 and Instruction	0920-0260	Specific Worker Questionnaire - example	Attachment F.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: 2,100	Number of Respondents for Small Entity: 1,700

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, 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	2,100	-1,600	3,700
Annual IC Time Burden (Hours)	1,050	-800	1,850
Annual IC Cost Burden (Dollars)	35,868	-27,328	63,196

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.