Information Collection

Evidence of Eligibility

IC 208114 under ICR 201604-1219-003 · OMB 1219-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0001 can be found here:

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	Evidence of Eligibility	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 75.153(a)(1) 30 CFR 75.153(a)(3) 30 CFR 77.103(a)(1) 30 CFR 77.103(a)(3)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 109	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	109	-91	200
Annual IC Time Burden (Hours)	55	-45	100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.