View Information Collection (IC)

View Information Collection (IC)

IC Title:	Att 12 Health and Wellness Screent (each test, fit testing)	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	Form ETB-1035 Rev 2	Health and Wellness Screening (each test, man testing)	Atch_11_Health and wellness screening (each test, fit testing).docx		Yes	Yes	Fillable Fileable Signable
Form	ETB-1254 Rev 0	ETB Anthropometric Datasheet	Atch_12a_DataCollectionForm (Facial Measurements).pdf		Yes	Yes	Fillable Fileable Signable

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: 10	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	100	0	100	0	0	0
Annual IC Time Burden (Hours)	25	0	25	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	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.