View Information Collection (IC)

View Information Collection (IC)

IC Title:	Att 10 OSHA/NPPTL Medical Evaluation: Annually for all Test Participants_Rev 1 (10.25.2023)	Agency IC Tracking Number:	0920-0109

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	0920-0109	OSHA/NPPTL Medical Evaluation: Annually for all Test ParticipantsRev 1 (10.25.2023)	Atch_10_Health and wellness screeining (annually, all test participants).pdf		Yes	Yes	Fillable Fileable
Form	0920-0109	Test Subject Information Sheet	Atch_10_InformationSheet.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	40	0	0	40	0	0
Annual IC Time Burden (Hours)	10	0	0	10	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Consent Form	Atch_8a_ConsentForm.pdf	11/14/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.