Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Employee - HHE Specific Medical Survey Informed Consent Modified 150 75 0 Form and Instruction 0920-0260 HHE Specific Medical Survey Informed Consent Form
Employee Representative - Closeout for HHE without Site Visit - Year 1 Modified 94 16 0 Form and Instruction 0920-0260 Followback Survey – One Year After - Final Letter
Employee Representative Closeout for HHE without Site Visit - Year 2 New 94 24 0 Form and Instruction 0920-0260 Followback Survey – One Year After Final Letter
Employees - Contact Postcard Modified 1425 119 0 Form and Instruction 0920-0260 HHE Contact Postcard
Employees - HHE Specific Questionnaire Example Modified 2900 1450 0 Form and Instruction 0920-0260 HHE Specific Questionnaire Example
Employees - HHE specific interview example Modified 1710 428 0 Form and Instruction 0920-0260 HHE - Specific Interview Example
Employees/ employee representatives/ or employers - HHE Request Form Modified 250 50 0 Form and Instruction 0920-0260 Request for a Health Hazard Evaluation - English
Form and Instruction 0920-0260 Request for a Health Hazard Evaluation - Spanish
Employer and Employee Representative - Closeout HHE Followback Survey with Site Visit Modified 140 47 0 Form and Instruction 0920-0260 Followback Survey – One Year After the Final Report
Employer and Employee Representative - Followback for Onsite Evaluations – Year 1 Modified 140 23 0 Form and Instruction 0920-0260 Followback Survey – After HHE Site Visit
Form and Instruction 0920-0260 Followback Survey – After HHE - Final Report
Employer and Employee Representative - HHE Followback Survey with Site Visit - Year 2 Modified 140 35 0 Form and Instruction 0920-0260 Followback Survey – After HHE Final Letter
Total burden requested under this ICR: 7043 2267 0  
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