Information Collection

Monthly Questionnaire

IC 213740 under ICR 201411-0920-002 · OMB 0920-1057.

Documents and Forms

Document Name Document Type
Monthly Questionnaire Form
monthly questionnaire Attch J-1-Monthly Questionnaire.docx Form
monthly questionnaire - Spanish Attch J-2-Monthly Questionnaire-Spanish.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Monthly 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	none	monthly questionnaire	Attch J-1-Monthly Questionnaire.docx		No		Paper Only
Form	none	monthly questionnaire - Spanish	Attch J-2-Monthly Questionnaire-Spanish.docx		No		Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

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

Number of Respondents: 960	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11,520	11,520
Annual IC Time Burden (Hours)	1,920	1,920
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.