Information Collection

1,3-Butadiene (29 CFR 1910.1051)

IC 14103 under ICR 201607-1218-021 · OMB 1218-0170.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1218-0170 can be found here:

Documents and Forms

Document Name Document Type
Form Appendix F to 1910 1,3-Butadiene (29 CFR 1910.1051) Form and Instruction
Appendix F to 1910 Medical Questionaires (Non-Mandatory) - 1,3-Butadiene (B 1910.1051 Butadiene - Initial Health Questionnaire.docx Form and Instruction
Appendix F to 1910 Medical Questionnaires (Non-Mandatory) 1,3-Butadiene (BD 1910.1051 Butadiene - Update Health Questionnaire.docx Form and Instruction
Butadiene Initial Health Questionnaire.pdf CFR Mark-up - Butadiene Initial health Questionnaire IC Document
Butadiene Update Health Questionnaire.pdf CFR Mark-up - Butadiene Update Health Questionnaire IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	1,3-Butadiene (29 CFR 1910.1051)	Agency IC Tracking Number:	1218-0170(2016)

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 1910.1051

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Appendix F to 1910.1051	Medical Questionaires (Non-Mandatory) - 1,3-Butadiene (BD) Initial Health Questionnaire	1910.1051 Butadiene - Initial Health Questionnaire.docx		Yes	No	Printable Only
Form and Instruction	Appendix F to 1910.1051	Medical Questionnaires (Non-Mandatory) 1,3-Butadiene (BD) Update Health Questionnaire	1910.1051 Butadiene - Update Health Questionnaire.docx		Yes	No	Printable Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	3,649	3,649
Annual IC Time Burden (Hours)	915	915
Annual IC Cost Burden (Dollars)	112,808	112,808

Documents for IC

Title	Document	Date Uploaded
CFR Mark-up - Butadiene Initial health Questionnaire	Butadiene Initial Health Questionnaire.pdf	08/08/2016
CFR Mark-up - Butadiene Update Health Questionnaire	Butadiene Update Health Questionnaire.pdf	08/08/2016

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