Information Collection

Signed Consent Forms for Medical Exams

IC 45140 under ICR 202104-1910-001 · OMB 1910-5112.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1910-5112 can be found here:

Documents and Forms

Document Name Document Type
Form DOE F 440.1 Signed Consent Forms for Medical Exams Form and Instruction
DOE F 440.1 Chronic Beryllium Disease Prevention Program Informed Co OMB 1910-5112 DOE F 440.1.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Signed Consent Forms for Medical Exams	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 850

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DOE F 440.1	Chronic Beryllium Disease Prevention Program Informed Consent	OMB 1910-5112 DOE F 440.1.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,624	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,632	650	5,982
Annual IC Time Burden (Hours)	1,658	162	1,496
Annual IC Cost Burden (Dollars)	207,250	15,424	191,826

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.