Last Symptom Check and Return to Work Clearance (food and nonfood employees)

Maritime Illness Database and Reporting System (MIDRS)

Documents and Forms

Document Name Document Type
Form 0920-1260 Last Symptom Check and Return to Work Clearance (food and nonfood employees) Form and Instruction
0920-1260 Last Symptom Check and Return to Work Clearance (food an Att5f LastSymptomCheck ReturnWorkClrnce (non-standard) 20220125.docx Form and Instruction
0920-1260 Last Symptom Check and Return to Work Clearance (food an Att5f LastSymptomCheck ReturnWorkClrnce (non-standard) 20220125.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Last Symptom Check and Return to Work Clearance (food and nonfood employees)	Agency IC Tracking Number:	0920-1260

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 and Instruction	0920-1260	Last Symptom Check and Return to Work Clearance (food and nonfood employees)	Att5f LastSymptomCheck ReturnWorkClrnce (non-standard) 20220125.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17,250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	17,250	17,250
Annual IC Time Burden (Hours)	862	862
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.