Information Collection

Respiratory Assessment Form - Spirometry Facility Employee

IC 212086 under ICR 202111-0920-021 · OMB 0920-0020.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0020 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC/NIOSH 2.13 (E) Respiratory Assessment Form - Spirometry Facility Employee	Form
CDC/NIOSH 2.13 (E) Respiratory Assessment Form Attachment 16.docx	Form
CDC/NIOSH 2.13 (E) Respiratory Assessment Form Attachment 16.docx	Form

IC Title:

Respiratory Assessment Form - Spirometry Facility Employee

Agency IC Tracking Number:

0920-0020

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	CDC/NIOSH 2.13 (E), rev 04/2016	Respiratory Assessment Form	Attachment 16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Mortality Studies in Coal Mining, Metal and Non-Metal Mining and General Industry â 09-20-0153

FR Citation: 51 FR 42478

Number of Respondents: 8,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,500	-6,060	14,560
Annual IC Time Burden (Hours)	708	-506	1,214
Annual IC Cost Burden (Dollars)	0	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.