Information Collection

Employees - HHE Specific Questionnaire Example

IC 185719 under ICR 202610-0920-015 · OMB 0920-0260.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0260 HHE Specific Questionnaire Example Employees - HHE Specific Questionnaire Example	Form and Instruction
0920-0260 HHE Specific Questionnaire Example Attachment D Sample HHE Specific Worker Questionnaire.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-0260

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	0920-0260			N/A	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: Occupational Health Epidemiological Studies

FR Citation: 76 FR 34706

Number of Respondents: 2,100

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: 50 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,100	-800	2,900
Annual IC Time Burden (Hours)	1,050	-400	1,450
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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