Information Collection

Att 11Pre-test Questionnaire for Respirator Fit Testing

IC 263410 under ICR 202311-0920-004 · OMB 0920-0109.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.