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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-24HM	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 %

table that charts list of burden
	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

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.