Information Collection

Former employee medical questionnaire

IC 243743 under ICR 202009-0920-016 · OMB 0920-1332.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1332 can be found here:

Documents and Forms

Document Name Document Type
Former employee medical questionnaire Form
Former employee medical questionnaire Attachment 3 Questionnaire.docx Form
Former employee medical questionnaire Attachment 3 Questionnaire.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Former employee medical 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	Former employee medical questionnaire	Attachment 3 Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

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

Number of Respondents: 338	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	338	338
Annual IC Time Burden (Hours)	254	254
Annual IC Cost Burden (Dollars)	5,831	5,831

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.