Information Collection

1,3-Butadiene (29 CFR 1910.1051) Appendix F

IC 240175 under ICR 201912-1218-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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) Appendix F Form and Instruction
29 CFR 1910.1051 A APPENDIX F TO § 1910.1051—MEDICAL QUESTIONNAIRES (NON-MA Butadiene Appendix F Public Burden Statement (03.02.20)ntc.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	1,3-Butadiene (29 CFR 1910.1051) Appendix F	Agency IC Tracking Number:	1218-0170(2020)

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 and Instruction	29 CFR 1910.1051 Appendix F	APPENDIX F TO Â§ 1910.1051âMEDICAL QUESTIONNAIRES (NON-MANDATORY))	Butadiene Appendix F Public Burden Statement (03.02.20)ntc.docx		Yes	No	Printable Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57	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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	426	426
Annual IC Time Burden (Hours)	213	213
Annual IC Cost Burden (Dollars)	14,827	14,827

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.