Information Collection

Last Symptom Check and Return to Work Clearance (food and nonfood employees)

IC 252606 under ICR 202603-0920-012 · OMB 0920-1260.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1260 Last Symptom Check and Return to Work Clearance (food and nonfood employees) Last Symptom Check and Return to Work Clearance (food and nonfood employees)	Form and Instruction
0920-1260 Last Symptom Check and Return to Work Clearance (food an Att5f LastSymptomCheck ReturnWorkClrnce (non-standard) 20220125.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1260

Is this a Common Form? No

IC Status: Modified

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 and Instruction	0920-1260				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18,000	750	17,250
Annual IC Time Burden (Hours)	900	38	862
Annual IC Cost Burden (Dollars)	0	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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