NOAA Health Services Questionnaire (NHSQ)

Office of Marine & Aviation Operations: Occupational Health, Safety, and Readiness Forms

Documents and Forms

Document Name Document Type
Form NF 57-10-01 NOAA Health Services Questionnaire (NHSQ) Form and Instruction
NF 57-10-01 NOAA Health Services Questionnaire NF 57-10-01 (01-25) NOAA Health Services Questionnaire.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	NOAA Health Services Questionnaire (NHSQ)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NF 57-10-01	NOAA Health Services Questionnaire	NF 57-10-01 (01-25) NOAA Health Services Questionnaire.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: COMMERCE/NOAA-22	FR Citation: 81 FR 10576

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	125	125
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.