Information Collection

Att 4_Standard Application Form

IC 6639 under ICR 202410-0920-021 · OMB 0920-0109.

Documents and Forms

Document Name Document Type
Form 0920-0109 Att 4_Standard Application Form Form
Form 0920-0109 Att 4_Standard Application Form Form
0920-0109 Standard Application Form Atch_4_SAF_v9.20190409_R.pdf Form
0920-0109 Standard Application Form Atch_4_SAF_v9.20190409_R.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 4_Standard Application Form	Agency IC Tracking Number:	0920-0109

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 84

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-0109	Standard Application Form	Atch_4_SAF_v9.20190409_R.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 140	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	560	560
Annual IC Time Burden (Hours)	128,240	128,240
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.