Information Collection

NOAA Health Services Questionnaire (NHSQ)

IC 264468 under ICR 202401-0648-010 · OMB 0648-0824.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0648-0824 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NF 57-10-01 NOAA Health Services Questionnaire (NHSQ)	Form and Instruction
NF 57-10-01 NOAA Health Services Questionnaire NF 57-10-01 Health Services Questionnaire.pdf	Form and Instruction
NF 57-10-01 NOAA Health Services Questionnaire NF 57-10-01 Health Services Questionnaire.pdf	Form and Instruction

IC Title:

NOAA Health Services Questionnaire (NHSQ)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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 and Instruction	NF 57-10-01	NOAA Health Services Questionnaire	NF 57-10-01 Health Services Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: COMMERCE/NOAA-22

FR Citation: 81 FR 10576

Number of Respondents: 500

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	500	500
Annual IC Time Burden (Hours)	125	125
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.