Att 10 OSHA/NPPTL Medical Evaluation: Annually for all Test Participants_Rev 1 (10.25.2023)

[NIOSH] Information Collection Provisions in 42 CFR Part 84 - Tests and Requirements for Certification and Approval of Respiratory Protective Devices

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0109 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0109 Att 10 OSHA/NPPTL Medical Evaluation: Annually for all Test Participants_Rev 1 (10.25.2023) Form
0920-0109 OSHA/NPPTL Medical Evaluation: Annually for all Test Par Atch_10_Health and wellness screeining (annually, all test participants).pdf Form
0920-0109 OSHA/NPPTL Medical Evaluation: Annually for all Test Par Atch_10_Health and wellness screeining (annually, all test participants).pdf Form
0920-0109 Test Subject Information Sheet Atch_10_InformationSheet.pdf Form
0920-0109 Test Subject Information Sheet Atch_10_InformationSheet.pdf Form
Atch_8a_ConsentForm.pdf Consent Form IC Document
Atch_8a_ConsentForm.pdf Consent Form IC Document

Information Collection (IC) Details

IC Title:	Att 10 OSHA/NPPTL Medical Evaluation: Annually for all Test Participants_Rev 1 (10.25.2023)	Agency IC Tracking Number:	0920-0109

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-0109	OSHA/NPPTL Medical Evaluation: Annually for all Test ParticipantsRev 1 (10.25.2023)	Atch_10_Health and wellness screeining (annually, all test participants).pdf		Yes	Yes	Fillable Fileable
Form	0920-0109	Test Subject Information Sheet	Atch_10_InformationSheet.pdf		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Consent Form	Atch_8a_ConsentForm.pdf	11/14/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.