Information Collection

1,3-Butadiene (29 CFR 1910.1051) Appendix F

IC 240175 under ICR 202602-1218-002 · OMB 1218-0170.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 29 CFR 1910.1051 A APPENDIX F TO § 1910.1051—MEDICAL QUESTIONNAIRES (NON-MANDATORY)) 1,3-Butadiene (29 CFR 1910.1051) Appendix F	Form and Instruction
29 CFR 1910.1051 A APPENDIX F TO § 1910.1051—MEDICAL QUESTIONNAIRES (NON-MA Butadiene Appendix F Public Burden Statement.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

1218-0170(2026)

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1910.1051

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 and Instruction	29 CFR 1910.1051 Appendix F				Yes	No	Printable Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	426	0	426
Annual IC Time Burden (Hours)	213	0	213
Annual IC Cost Burden (Dollars)	22,578	7,124	15,454

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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