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Agenda
Reg Review
ICR
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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