View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Signed Consent Forms for Medical Exams	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 850

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DOE F 440.1	Chronic Beryllium Disease Prevention Program Informed Consent Form	DOE F 440.1 Chronic Beryllium Disease Prevention Program Informed Consent Form (03_2022) Final.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,624	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	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	6,632	0	0	650	0	5,982
Annual IC Time Burden (Hours)	1,658	0	0	162	0	1,496
Annual IC Cost Burden (Dollars)	207,250	0	0	15,424	0	191,826

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.