HHE Specific Worker 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⚠️ Notice: This information collection may be referencing outdated material.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
HHE Specific Worker Questionnaire (Example) Form
HHE Specific Worker Questionnaire - example Attachment F_Sample HHE Specific Worker Questionnaire.docx Form

Information Collection (IC) Details

IC Title:	HHE Specific Worker 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 Specific Worker Questionnaire - example	Attachment F_Sample HHE Specific Worker Questionnaire.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Occupational Health Epidemiological Studies	FR Citation: 76 FR 34706

Number of Respondents: 3,800	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	3,800	360	3,440
Annual IC Time Burden (Hours)	1,900	180	1,720
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.