Information Collection

Participant Eligibility Screening Form

IC 248533 under ICR 202107-0920-008 · OMB 0920-1345.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-20BY Participant Eligibility Screening Form	Form
Form 0920-20BY Comments_AttachmentC_LSHSurvey_April 22 2021 Participant Eligibility Screening Form	Form
0920-20BY Comments_AttachmentC_LSHSurvey_April 22 2021 Comments_AttachmentC_LSHSurvey_April 22 2021.docx	Form
0920-20BY Comments_AttachmentC_LSHSurvey_April 22 2021 Comments_AttachmentC_LSHSurvey_April 22 2021.docx	Form

IC Title:

Agency IC Tracking Number:

0920-20BY

Is this a Common Form? Yes

IC Status: New

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	0920-20BY				Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

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.

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