Information Collection

Essential Questionnaire

IC 192031 under ICR 202605-0923-001 · OMB 0923-0041.

Documents and Forms

Document Name Document Type
Essential Questionnaire Essential Questionnaire Form and Instruction
Essential Questionnaire APPENDIX E - Surveys - clean.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Essential Questionnaire	Agency IC Tracking Number:	0923-26-0185

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Essential Questionnaire	APPENDIX E - Surveys - clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 76 FR 4432

Number of Respondents: 750	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	750	750
Annual IC Time Burden (Hours)	75	75
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.

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