Information Collection

Impacted Person Reporting Election Form

IC 261873 under ICR 202308-0648-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Impacted Person Reporting Election Form	Form and Instruction
Impacted Person Reporting Election Statement Impacted Person Reporting Election Statement.pdf	Form and Instruction

IC Title:

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	N/A	Impacted Person Reporting Election Statement	Impacted Person Reporting Election Statement.pdf		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 78

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	78	78
Annual IC Time Burden (Hours)	78	78
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.