Att D1- Personal History

A Longitudinal Examination of Mental and Physical Health among Police Associated with COVID–19

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1350 can be found here:

Documents and Forms

Document Name Document Type
Form 0920 Att D1- Personal History Form
0920 Personal History Attachment D1- Personal History.docx Form
0920 Personal History Attachment D1- Personal History.docx Form

Information Collection (IC) Details

IC Title:	Att D1- Personal History	Agency IC Tracking Number:	0920-21CG

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	0920	Personal History	Attachment D1- Personal History.docx		No		Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	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	180	180
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	0	0

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.