Att 11Pre-test Questionnaire for Respirator Fit Testing

[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⚠️ Notice: This information collection may be referencing outdated material.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 11Pre-test Questionnaire for Respirator Fit Testing Form
0920-0109 Pre-test Questionnaire for Respirator Fit Testing Atch_11_Health and wellness screening (each test, fit testing).docx Form
0920-0109 Pre-test Questionnaire for Respirator Fit Testing Atch_11_Health and wellness screening (each test, fit testing).docx Form
W-9 Request for Identification Number and Certification Atch_11_ParticipantPaymentInfo.pdf Form
W-9 Request for Identification Number and Certification Atch_11_ParticipantPaymentInfo.pdf Form

Information Collection (IC) Details

IC Title:	Att 11Pre-test Questionnaire for Respirator Fit Testing	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	Pre-test Questionnaire for Respirator Fit Testing	Atch_11_Health and wellness screening (each test, fit testing).docx		Yes	Yes	Fillable Fileable
Form	W-9	Request for Identification Number and Certification	Atch_11_ParticipantPaymentInfo.pdf		Yes	Yes	Fillable Fileable Signable

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.