Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Att 10 OSHA/NPPTL Medical Evaluation: Annually for all Test Participants_Rev 1 (10.25.2023) New 40 10 0 Form 0920-0109 OSHA/NPPTL Medical Evaluation: Annually for all Test ParticipantsRev 1 (10.25.2023)
Form 0920-0109 Test Subject Information Sheet
Att 11Pre-test Questionnaire for Respirator Fit Testing New 800 80 0 Form 0920-0109 Pre-test Questionnaire for Respirator Fit Testing
Form W-9 Request for Identification Number and Certification
Att 12 Health and Wellness Screent (each test, fit testing) New 100 25 0 Form Form ETB-1035 Rev 2 Health and Wellness Screening (each test, man testing)
Form ETB-1254 Rev 0 ETB Anthropometric Datasheet
Att 13 Data Collection Form (Man testing) New 100 75 0 Form 0920-0109 Man Test 1, SCBA -Operating and Breathing (30 min)
Att 14 Capacity Test New 10 1 0 Form 0920-0109 Determination of Capacity (CCER)
Att 15 Communication Test New 10 20 0 Form 0920-0109 CBRN APR Communication Performance Test Data Analysis Sheets
Att 16 Donning Test New 10 10 0 Form 0920-0109 Donning
Att 17 Fit Test STP 5_5.1_6 New 280 42 0 Form TEB-1023 Rev.1 Subject Template (Fit test STP 5_5.1_6)
Att 18 Fit Test STP -9 and 10 New 280 42 0 Form ETB-1028 Rev 5 Fit Testing Report
Att 19 Fogging test New 10 5 0 Form TEB-1107 Rev 0 CBRN APR Lens FOgging Test Data Collection Sheet
Att 20 LRPL Bitrex Donning New 38 38 0 Form TEB-1107 Rev 0 Fit Test Data (PortaCount, PortaCount Plus, Corn Oil, Bitrex
Att 21 Performance Test New 10 10 0 Form TEB-1214A Rev 0 Determination of Performance Form
Att 22 Sound Level STP-30_STP 111 New 50 5 0 Form ETB-1014-APR -0030 Rev 3 Determination of Noise Level Test Data Sheet
Att 23 Stressors New 10 10 0 Form ETB-1214 Rev 1 FPW Determination of Performance Form
Att 24 Test 118 New 250 125 0 Form 0920-0109 Cold Temperature Test, Open Circuit, SCBA STP #: 118
Att 25 Test 147 New 40 6 0 Form 0920-0109 Special Test - Model Transfer- Combination, Open-Circuit, SCBA and Supplied Air Respirators, SCBA/SAR STP#: 147
Att 26 Wearability Test New 10 3 0 Form ETB 1211A Rev 1 FPW Determination of Wearability (CCER)
Att 4_Standard Application Form Modified 560 128240 0 Form 0920-0109 Standard Application Form
Att 5_Request manufacturing code New 10 5 0 Form and Instruction 0920-0109 NIOSH RESPIRATOR APPROVAL PROGRAM QUESTIONNAIRE FOR POTENTIAL APPLICANTS
Att 7_Site audits, Part 1_Respiratory Protective Devices-42 CFR part 84-Regulation (Audit) Modified 85 43 0 Form 0920-0109 Audit Form
Att 7b_Site audits, Part 2_Respiratory Protective Devices-42 CFR part 84-Regulation (Audit) New 85 13 0 Form 0920-0109 Audit Form
Att 7c_Site audits,Site audits (completed for each corrective action) New 140 2240 0 Form 0920-0109 NIOSH CORRECTIVE ACTION REQUEST (CAR) Form
Att 8_Test Participant Information Sheet New 10 2 0 Form 0920-0109 Test Participant Information Sheet
Att 9 Pre- and Post-Test Session Participant Questionnaire and Examination New 40 10 0 Form 0920-0109 Pre- and Post-Test Session Participant Questionnaire and Examination
Total burden requested under this ICR: 2978 131060 0  
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