Information Collection

Appx I_ Pre-Test Questionnaire (M/FF/CW)

IC 243405 under ICR 202310-0920-010 · OMB 0920-1331.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix I Pre-test screening.docx	Other-App (WORD)
Appendix I Pre-test screening.docx	Other-App (WORD)

IC Title:

Agency IC Tracking Number:

0920-20HO

Is this a Common Form? No

IC Status: Unchanged

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
Other-App (WORD)					Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	3	3
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.

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