Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Att C_Request for a Health Hazard Evaluation (Employees and Employers) Modified 250 50 1708 Form 0920-0260 HHE Request Form
Att D_Sample HHE Specific Worker Interview Modified 1470 368 12554 Form 0920-0260 HHE Specific Worker Interview - example
Att F_Sample HHE Specific Worker Questionnaire Modified 2100 1050 35868 Form and Instruction 0920-0260 Specific Worker Questionnaire - example
Att G_Sample Employee Contact Information Postcard Modified 1225 102 3491 Form 0920-0260 Sample Employee Contact Information Postcard
Att H_ Initial Site Visit Followback Survey Form Modified 140 23 797 Form 0920-0260 Initial Site Visit Followback Survey Form
Att I_ HHE Survey - FINAL Report (with site visit) Modified 140 47 1593 Form 0920-0260 HHE Survey - FINAL Report
Att J_HHE Followback Survey - FINAL Report - 1Yr Later Modified 140 35 1196 Form 0920-0260 HHE Followback Survey - FINAL Report - 1YR Later
Att K_Followback Survey – Final Letter Modified 94 16 535 Form 0920-0260 Followback Survey (Closeout for HHE without site vite)
Att L_Followback Survey: One Year Later Modified 94 24 803 Form 0920-0260 Followback without Onsite Evaluation - year 1
Total burden requested under this ICR: 5653 1715 58545  
To view an IC, click on IC Title