Information Collection

Daily Pre-Shift Questionnaires

IC 266348 under ICR 202503-0920-018 · OMB 0920-1436.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-23HM Daily Pre-Shift Questionnaires	Form
Form 0920-23HM Daily Pre-Shift Questionnaires Daily Pre-Shift Questionnaires	Form
Form 0920-23HM Daily Pre-Shift Questionnaires_Spanish Daily Pre-Shift Questionnaires	Form
0920-23HM Daily Pre-Shift Questionnaires Attachment 3c - Questionnaire_PreShift_Fatigue OGE.docx	Form
0920-23HM Daily Pre-Shift Questionnaires Attachment 3c - Questionnaire_PreShift_Fatigue OGE.docx	Form
0920-23HM Daily Pre-Shift Questionnaires_Spanish Attachment 3d - Questionnaire_PreShift_Fatigue OGE- ES.docx	Form
0920-23HM Daily Pre-Shift Questionnaires_Spanish Attachment 3d - Questionnaire_PreShift_Fatigue OGE- ES.docx	Form

IC Title:

Agency IC Tracking Number:

0920-23HM

Is this a Common Form? Yes

IC Status: Unchanged

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	0920-23HM				Yes	Yes	Fillable Fileable
Form	0920-23HM				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

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	Previously Approved
Annual Number of Responses for this IC	1,120	1,120
Annual IC Time Burden (Hours)	56	56
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.

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