Hazardous Substances Emergency Events Surveillance Data Request Form

Hazardous Substances Emergency Events Surveillance

Documents and Forms

Document Name Document Type
appendix 3a - DataRequestForm2005.pdf Other-data request form

Information Collection (IC) Details

IC Title:	Hazardous Substances Emergency Events Surveillance Data Request Form	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 103

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-data request form			appendix 3a - DataRequestForm2005.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	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.