Information Collection

Appx C_Initial Participant Questionnaire: Field (Health screening)

IC 243129 under ICR 202310-0920-010 · OMB 0920-1331.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1331 Appx C_Initial Participant Questionnaire: Field (Health screening)	Form and Instruction
0920-1331 Initial Participant Questionnaire: Field Appendix C Health screening - field.docx	Form and Instruction
0920-1331 Initial Participant Questionnaire: Field Appendix C Health screening - field.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1331

Is this a Common Form? No

IC Status: Modified

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	0920-1331	Initial Participant Questionnaire: Field	Appendix C Health screening - field.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	15	15
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.