Employer and Employee Representative - Closeout HHE Followback Survey with Site Visit

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

Documents and Forms

Document Name Document Type
Form 0920-0260 Employer and Employee Representative - Closeout HHE Followback Survey with Site Visit Form and Instruction
0920-0260 Followback Survey – One Year After the Final Report Attachment I 1 Year Later After Final Report Followback Survey Form.docx Form and Instruction
0920-0260 Followback Survey – One Year After the Final Report Attachment I 1 Year Later After Final Report Followback Survey Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Employer and Employee Representative - Closeout HHE Followback Survey with Site Visit	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	Followback Survey – One Year After the Final Report	Attachment I 1 Year Later After Final Report Followback Survey Form.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: 140	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	140	0	140
Annual IC Time Burden (Hours)	47	12	35
Annual IC Cost Burden (Dollars)	0	-1,196	1,196

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.