Information Collection

Signed Consent Forms for Medical Exams

IC 45140 under ICR 202603-1910-003 · OMB 1910-5112.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DOE F 440.1 Chronic Beryllium Disease Prevention Program Informed Consent Form Signed Consent Forms for Medical Exams	Form and Instruction
DOE F 440.1 Chronic Beryllium Disease Prevention Program Informed Co DOE_F_440.1_Chronic_Beryllium_Disease_Prevention_Program_Informed_Consent_Form.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 850

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	DOE F 440.1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,444

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: 55 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	6,445	-187	6,632
Annual IC Time Burden (Hours)	1,611	-47	1,658
Annual IC Cost Burden (Dollars)	239,072	31,822	207,250

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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