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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.