Employee - HHE Specific Medical Survey Informed Consent

[NIOSH] Health Hazard Evaluations/Technical Assistance and Emerging Problems

Documents and Forms

Document Name Document Type
Form 0920-0260 Employee - HHE Specific Medical Survey Informed Consent Form and Instruction
0920-0260 HHE Specific Medical Survey Informed Consent Form Attachment E Medical Survey Informed Consent Example.docx Form and Instruction
0920-0260 HHE Specific Medical Survey Informed Consent Form Attachment E Medical Survey Informed Consent Example.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Employee - HHE Specific Medical Survey Informed Consent	Agency IC Tracking Number:	0920-0260

Is this a Common Form? No		IC Status: Modified

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 and Instruction	0920-0260	HHE Specific Medical Survey Informed Consent Form	Attachment E Medical Survey Informed Consent Example.docx	N/A	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies	FR Citation: 76 FR 34706

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	150	10	140
Annual IC Time Burden (Hours)	75	52	23
Annual IC Cost Burden (Dollars)	0	-797	797

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.