Information Collection

1,3-Butadiene (29 CFR 1910.1051)

IC 14103 under ICR 201809-1218-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 29 CFR 1910.1051 A 1,3-Butadiene (29 CFR 1910.1051) Form
29 CFR 1910.1051 A Medical Questionnaires (Non-Mandatory); 1,3 Butadiene In SIP IV Final Rule - Butadiene Appendix F Public Burden Statement (03.27.19).docx Form
butadiene app f mark-up.pdf Appendix F mark-up 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(2018)SIPIV

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	29 CFR 1910.1051 Appendix F	Medical Questionnaires (Non-Mandatory); 1,3 Butadiene Initial Health Questionnaire; 1,3-Butadiene Update Health Questionnaire	SIP IV Final Rule - Butadiene Appendix F Public Burden Statement (03.27.19).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 %

	Approved	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
Appendix F mark-up	butadiene app f mark-up.pdf	09/24/2018

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