Health Screening Consent / Contact Form

National Healthy Worksite Program

Documents and Forms

Document Name Document Type
Attachment_G-1_NHWP_Employee_Consent_Contact_Form.doc Other-null

Information Collection (IC) Details

IC Title:	Health Screening Consent / Contact Form	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
Other-null			Attachment_G-1_NHWP_Employee_Consent_Contact_Form.doc		No		Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,713	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
Annual Number of Responses for this IC	5,713	5,713
Annual IC Time Burden (Hours)	952	952
Annual IC Cost Burden (Dollars)	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.