Information Collection

Former employee medical questionnaire

IC 243743 under ICR 202109-0920-011 · OMB 0920-1332.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Former employee medical questionnaire	Form
Former employee medical questionnaire Attachment 3 Questionnaire.docx	Form
Former employee medical questionnaire Attachment 3 Questionnaire.docx	Form

IC Title:

Agency IC Tracking Number:

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	none	Former employee medical questionnaire	Attachment 3 Questionnaire.docx		Yes	Yes	Fillable Fileable

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	338	338
Annual IC Time Burden (Hours)	254	254
Annual IC Cost Burden (Dollars)	5,831	5,831

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.