Information Collection

Baseline Questionnaire

IC 266347 under ICR 202403-0920-015 · OMB 0920-1436.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1436 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-23HM Baseline Questionnaire Form
0920-23HM Baseline Questionnaire Attachment 3a - Questionnaire_Baseline_Fatigue OGE.docx Form
0920-23HM Baseline Questionnaire_Spanish Attachment 3b - Questionnaire_Baseline_Fatigue OGE - ES.docx Form
0920-24HM Attachment 3a - Questionnaire_Baseline Attachment 3a - Questionnaire_Baseline_Fatigue OGE_FINAL_2024-05-13.docx Form
0920-24HM Attachment 3b - Questionnaire_Baseline_ ES Attachment 3b - Questionnaire_Baseline_Fatigue OGE_ FINAL - ES_2024-05-13.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline Questionnaire	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

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	0920-24HM	Attachment 3a - Questionnaire_Baseline	Attachment 3a - Questionnaire_Baseline_Fatigue OGE_FINAL_2024-05-13.docx		Yes	Yes	Fillable Fileable
Form	0920-24HM	Attachment 3b - Questionnaire_Baseline_ ES	Attachment 3b - Questionnaire_Baseline_Fatigue OGE_ FINAL - ES_2024-05-13.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

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.