Information Collection

Work and Health Survey

IC 260949 under ICR 202305-0920-015 · OMB 0920-1413.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1413 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Work and Health Survey	Form and Instruction
Work and Health Survey Attachment 5a - Work and Health Survey.docx	Form and Instruction
Work and Health Survey Attachment 5a - Work and Health Survey.docx	Form and Instruction

IC Title:

Work and Health Survey

Agency IC Tracking Number:

Is this a Common Form? No

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 and Instruction	None	Work and Health Survey	Attachment 5a - Work and Health Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program Records

FR Citation: 76 FR 34706

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	338	338
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.