Information Collection

Web-based Initial Survey

IC 193089 under ICR 201005-0920-007 · OMB 0920-0851.

Documents and Forms

Document Name Document Type
Form No number Web-based Initial Survey Form
No number Web-based Survey NIOSH_Intake_Survey_052810.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Web-based Initial Survey	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	No number	Web-based Survey	NIOSH_Intake_Survey_052810.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	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	3,500	3,500
Annual IC Time Burden (Hours)	292	292
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.