Information Collection

Maintenance Shift Worker Form

IC 190839 under ICR 200909-0920-014 · OMB 0920-0829.

Documents and Forms

Document Name Document Type
Maintenance Shift Worker Form Form
Maintenance Shift Worker Form Attachment 5 - Maintenance Shift Worker Form (2).doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Maintenance Shift Worker Form	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	none	Maintenance Shift Worker Form	Attachment 5 - Maintenance Shift Worker Form (2).doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 10

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	2	2
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.