Information Collection

Att 4_Standard Application Form

IC 6639 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⚠️ Notice: This information collection may be referencing outdated material.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 4_Standard Application Form	Form
0920-0109 Standard Application Form Atch_4_SAF_v9.20190409_R.pdf	Form
0920-0109 Standard Application Form Atch_4_SAF_v9.20190409_R.pdf	Form

IC Title:

Att 4_Standard Application Form

Agency IC Tracking Number:

0920-0109

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 84

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	Standard Application Form	Atch_4_SAF_v9.20190409_R.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 140

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	560	560
Annual IC Time Burden (Hours)	128,240	128,240
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.