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Att 12 Health and Wellness Screent (each test, fit testing)
[NIOSH] Information Collection Provisions in 42 CFR Part 84 - Tests and Requirements for Certification and Approval of Respiratory Protective Devices
OMB: 0920-0109
IC ID: 263411
OMB.report
HHS/CDC
OMB 0920-0109
ICR 202410-0920-021
IC 263411
( )
Documents and Forms
Document Name
Document Type
Form Form ETB-1035 Rev
Att 12 Health and Wellness Screent (each test, fit testing)
Form
Form Form ETB-1035 Rev
Att 12 Health and Wellness Screent (each test, fit testing)
Form
Form ETB-1035 Rev Health and Wellness Screening (each test, man testing)
Atch_11_Health and wellness screening (each test, fit testing).docx
Form
Form ETB-1035 Rev Health and Wellness Screening (each test, man testing)
Atch_11_Health and wellness screening (each test, fit testing).docx
Form
ETB-1254 Rev 0 ETB Anthropometric Datasheet
Atch_12a_DataCollectionForm (Facial Measurements).pdf
Form
ETB-1254 Rev 0 ETB Anthropometric Datasheet
Atch_12a_DataCollectionForm (Facial Measurements).pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Att 12 Health and Wellness Screent (each test, fit testing)
Agency IC Tracking Number:
0920-0109
Is this a Common Form?
No
IC Status:
Unchanged
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
Form ETB-1035 Rev 2
Health and Wellness Screening (each test, man testing)
Atch_11_Health and wellness screening (each test, fit testing).docx
Yes
Yes
Fillable Fileable Signable
Form
ETB-1254 Rev 0
ETB Anthropometric Datasheet
Atch_12a_DataCollectionForm (Facial Measurements).pdf
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Worker Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
10
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
100
0
0
0
0
100
Annual IC Time Burden (Hours)
25
0
0
0
0
25
Annual IC Cost Burden (Dollars)
0
0
0
0
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.