Airborne Hazards And Open Burn Pit Registry Self-Assessment Questionnaire

Open Burn Pit Registry Web-accessible Self-Assessment/Questionnaire

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0800 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 10-10066 Airborne Hazards And Open Burn Pit Registry Self-Assessment Questionnaire Form
VA Form 10-10066 Airborne Hazards And Open Burn Pit Registry Self-Assessm VA Form 10-10066_Open Burn Pit Registry Self-Assessment Questionnaire_20140324.pdf Form

Information Collection (IC) Details

IC Title:	Airborne Hazards And Open Burn Pit Registry Self-Assessment 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	VA Form 10-10066	Airborne Hazards And Open Burn Pit Registry Self-Assessment Questionnaire	VA Form 10-10066_Open Burn Pit Registry Self-Assessment Questionnaire_20140324.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	33,333	33,333
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.