Information Collection

Annual Questionnaire

IC 213739 under ICR 201411-0920-002 · OMB 0920-1057.

Documents and Forms

Document Name Document Type
Annual Questionnaire Form
Annual Questionnaire Attch I-1 - Annual Questionnaire_2014_10_17.docx Form
Annual Questionnaire - Spanish Attch. I-2 - Annual Questionnaire-Spanish_2014_10_17.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	none	Annual Questionnaire	Attch I-1 - Annual Questionnaire_2014_10_17.docx		No		Paper Only
Form	none	Annual Questionnaire - Spanish	Attch. I-2 - Annual Questionnaire-Spanish_2014_10_17.docx		No		Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies and EEOICPA Program Records	FR Citation: 76 FR 34706

Number of Respondents: 960	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	960	960
Annual IC Time Burden (Hours)	480	480
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.