Information Collection

Consent

IC 243752 under ICR 202009-0920-016 · OMB 0920-1332.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1332 can be found here:

Documents and Forms

Document Name Document Type
Consent Form and Instruction
Consent Attachment 19 Consent form_Questionnaire and medical survey.docx Form and Instruction
Consent Attachment 19 Consent form_Questionnaire and medical survey.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Consent	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	none	Consent	Attachment 19 Consent form_Questionnaire and medical survey.docx		No		Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records	FR Citation: 76 FR 34706

Number of Respondents: 338	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	338	338
Annual IC Time Burden (Hours)	85	85
Annual IC Cost Burden (Dollars)	1,944	1,944

Documents for IC

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.