Information Collection

Att 12 Health and Wellness Screent (each test, fit testing)

IC 263411 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⚠️ Notice: This information collection may be referencing outdated material.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 Form ETB-1035 Rev Att 12 Health and Wellness Screent (each test, fit testing)	Form
Form Form ETB-1035 Rev Health and Wellness Screening (each test, man testing) Att 12 Health and Wellness Screent (each test, fit testing)	Form
Form ETB-1254 Rev 0 ETB Anthropometric Datasheet Att 12 Health and Wellness Screent (each test, fit testing)	Form
Form ETB-1035 Rev Health and Wellness Screening (each test, man testing) Atch_11_Health and wellness screening (each test, fit testing).docx	Form
Form ETB-1035 Rev Health and Wellness Screening (each test, man testing) Atch_11_Health and wellness screening (each test, fit testing).docx	Form
ETB-1254 Rev 0 ETB Anthropometric Datasheet Atch_12a_DataCollectionForm (Facial Measurements).pdf	Form
ETB-1254 Rev 0 ETB Anthropometric Datasheet Atch_12a_DataCollectionForm (Facial Measurements).pdf	Form

IC Title:

Att 12 Health and Wellness Screent (each test, 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	Form ETB-1035 Rev 2				Yes	Yes	Fillable Fileable Signable
Form	ETB-1254 Rev 0				Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	100	100
Annual IC Time Burden (Hours)	25	25
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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