Health Hazard Evaluation Specific Questionnaire (Example)

Health Hazard Evaluations/Technical Assistance and Emerging Problems

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0260 can be found here:

Documents and Forms

Document Name Document Type
Health Hazard Evaluation Specific Questionnaire (Example) Form
HHE Evaluation Attachment F- updated.docx Form

Information Collection (IC) Details

IC Title:	Health Hazard Evaluation Specific Questionnaire (Example)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	HHE Evaluation	Attachment F- updated.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies	FR Citation: 51 FR 42449

Number of Respondents: 3,440	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,440	-1,000	4,440
Annual IC Time Burden (Hours)	1,720	-500	2,220
Annual IC Cost Burden (Dollars)	0	0	0

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.