Health Hazard Evaluation Program Customer Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form no number Customer Focus Group Screener	Form	New	Available
Form no number Customer Survey	Form	New	Available
Form no number Customer Survey Pretest	Form	New	Available
Attachment D Focus Group Screener[01-07-09].doc	Supplementary Document	Uploaded 2009-01-23	Available
Attachment C-2 Workplace Hlt Haz Survey[01-07-09].doc	Supplementary Document	Uploaded 2009-01-23	Available
Attachment H Consent Form Revised.doc	Supplementary Document	Uploaded 2009-01-22	Available
Attachment C-1 Letter of Invitation Revised.doc	Supplementary Document	Uploaded 2009-01-22	Available
HHE ICR Part B Revision 3.doc	Supporting Statement B	Uploaded 2009-01-22	Available
Attachment H Consent Form Revised.doc	Supplementary Document	Uploaded 2008-10-28	Available
Attachment G AED IRB Review.doc	Supplementary Document	Uploaded 2008-10-28	Available
Attachment F-2 HSRB2.doc	Supplementary Document	Uploaded 2008-10-28	Repair queued
Attachment F-1 HSRB1.doc	Supplementary Document	Uploaded 2008-10-28	Repair queued
Attachment B 60Day FRN.doc	Supplementary Document	Uploaded 2008-10-28	Available
Attachment A-4 Public Health Service Act 42USC241final.doc	Supplementary Document	Uploaded 2008-10-28	Available
Attachment A-3 Title 42 CFR Parts 85 and 85a.doc	Supplementary Document	Uploaded 2008-10-28	Available
Attachment A-2 PL 91-173.doc	Supplementary Document	Uploaded 2008-10-28	Available
Attachment A-1 PL 91-596.doc	Supplementary Document	Uploaded 2008-10-28	Available
Attachment C-3 Research Question Matrix.doc	Supplementary Document	Uploaded 2008-10-28	Available
Attachment C-1 Letter of Invitation Revised.doc	Supplementary Document	Uploaded 2008-10-28	Available
HHE ICR Part A Revision 3.doc	Supporting Statement A	Uploaded 2009-01-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
187119	Customer Focus Group Material Testing	Instruction	New
187118	Customer Focus Group Concept Testing	Instruction	New
187117	Customer Focus Group Screener	Form	New
187116	Customer Survey	Form	New
187115	Customer Survey Pretest	Form	New

ICR Details

OMB Control No: 0920-0803	ICR Reference No: 200811-0920-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Health Hazard Evaluation Program Customer Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/30/2009
	Date Received in OIRA: 11/06/2008
Terms of Clearance: Approved consisent with changes made to documents as uploaded on 1/23/09.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2012	36 Months From Approved
Responses	6,224	0	0
Time Burden (Hours)	1,880	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC's National Institute for Occupational Safety and Health (NIOSH) proposes to conduct a program of quantitative and qualitative research to help ensure that the Health Hazard Evaluation Program is responsive to the needs of its customers and enhances the diversity of workplaces and hazards assessed.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
   US Code: 42 USC 85-85a Name of Law: Request for Health Hazard Evaluation
   US Code: 42 USC 20 Name of Law: Occupational Safety and Health Act
   US Code: 42 USC 301 Name of Law: Federal Mine Safety and Health Act
   US Code: 42 USC 501 Name of Law: Federal Mine Safety and Health Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 26997	05/12/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 64617	10/30/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Customer Survey Pretest	no number	Survey Pretest
Customer Focus Group Concept Testing
Customer Focus Group Material Testing
Customer Survey	no number	Customer Survey
Customer Focus Group Screener	no number	Focus Group Screener

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,224	0	0	6,224	0	0
Annual Time Burden (Hours)	1,880	0	0	1,880	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new data collection request.

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Annual Cost to Federal Government: $129,579

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/06/2008

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