Information Collection

Att D2- Medical History

IC 248339 under ICR 202110-0920-005 · OMB 0920-1350.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920 Att D2- Medical History	Form
0920 Medical History Attachment D2- Medical History.docx	Form
0920 Medical History Attachment D2- Medical History.docx	Form

IC Title:

Agency IC Tracking Number:

0920-21CG

Is this a Common Form? No

IC Status: Unchanged

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	Medical History	Attachment D2- Medical History.docx		No		Fillable Fileable

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	360	360
Annual IC Time Burden (Hours)	48	48
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.