Information Collection

Appendix A

IC 225683 under ICR 202308-1218-003 · OMB 1218-0065.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Appendix A Appendix A	Form and Instruction
Appendix A Sample Authorization Letter for the Release of Employee Appendix A for 1218-0065.pdf	Form and Instruction
Appendix A Sample Authorization Letter for the Release of Employee Appendix A for 1218-0065.pdf	Form and Instruction

IC Title:

Appendix A

Agency IC Tracking Number:

1218-0065(2023)

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1910.1020(e)(2)(ii)(B) 29 CFR 1910 Appendix A

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	Appendix A	Sample Authorization Letter for the Release of Employee Medical Record Information to a Designated Representative (Non-Mandatory)	Appendix A for 1218-0065.pdf		No		Printable Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 790,164

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 5 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,804	470	15,334
Annual IC Time Burden (Hours)	1,317	39	1,278
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.