Musculoskeletal Disorder (MSD) Intervention Effectiveness in Wholesale/ Retail Trade Operations

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8 Early Exit Interview	Form and Instruction	New	Available
Form 7 Low Back Functional Assessment	Form and Instruction	New	Available
Form 6 Self-Reported General Work Environment and Health Questionnaire	Form and Instruction	New	Available
Form 5 Self-Reported Specific Job Tasks and Safety Incidents Questionnaire	Form and Instruction	New	Available
Form 4 Self-Reported Upper Extremity Pain Questionnaire	Form and Instruction	New	Available
Form 3 Self-reported low back pain questionnaire	Form and Instruction	New	Available
Form 2 Informed Consent- Low Back Functional Assessment	Form and Instruction	New	Available
Form 1 Informed Consent (Questionnaire Data Collection)	Form and Instruction	New	Available
Attch L-5 Study Limitations.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch L-4. Framing a Cost Benefit Analyses.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch J-4.Individual Recruitment Flyer.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch J-3 Volunteer Employee Responsibilities.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch J-2 OBWC Safety Grants App.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch J-1 Establishment Recruitment Flyer.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch I Low Back Functional Assessment.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch H-5 Early Exit Interview.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch H-4 self-reported general work environment and health quest.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch H-3 Self-reported specifc job tasks and safety incidents.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch H-2 Self-reported shoulder-arm pain quest.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch H-1 Self-reported low back pain.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attachment L-2 MSD Intervention Study Design Revised 11_1_11.docx	Supplementary Document	Uploaded 2011-11-04	Available
Attch L-1 Details of Interventions.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attachment L-3 Descriptions of Outcome Measures Revised 11_1_11.docx	Supplementary Document	Uploaded 2011-11-04	Available
Attch K IRB approval.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch G-3. Verbal Consent of Photographic Image Release.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch G-2. Informed Consent Low Back Functional Assessment.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch G-1.Informed Consent-Questionnaire.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch F. Information Security Plan.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch E-3. Comparison of US and OH NAICS codes.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch E-2. Letter of Support from OBWC.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch E-1 OBWC-NIOSH Letter of Agreement.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch D-2. Prior MSD Intervention Studies.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attch D-1.Relation of Project to Res. Agenda.docx	Supplementary Document	Uploaded 2011-10-28	Available
Attachment C NIOSH Strategic Goals revised 11_1_11.docx	Supplementary Document	Uploaded 2011-11-04	Available
Section B MSD Intervention Revised 11_1_11.doc	Supporting Statement B	Uploaded 2011-11-04	Available
Attachment L-5.docx	Supplementary Document	Uploaded 2011-08-08	Available
Attachment L-4.docx	Supplementary Document	Uploaded 2011-08-08	Available
Attachment L-3.docx	Supplementary Document	Uploaded 2011-08-08	Available
Attachment L-2 .docx	Supplementary Document	Uploaded 2011-08-08	Available
Attachment L-1.docx	Supplementary Document	Uploaded 2011-08-08	Available
Attachment J-4.docx	Supplementary Document	Uploaded 2011-08-08	Available
Attachment J-3.docx	Supplementary Document	Uploaded 2011-08-08	Available
Attachment J-2.docx	Supplementary Document	Uploaded 2011-08-08	Available
Attachment J-1.docx	Supplementary Document	Uploaded 2011-08-08	Available
Attachment F.docx	Supplementary Document	Uploaded 2011-07-27	Available
Attachment E-3.docx	Supplementary Document	Uploaded 2011-07-27	Available
Attachment E-2.docx	Supplementary Document	Uploaded 2011-07-27	Available
Attachment D-2.docx	Supplementary Document	Uploaded 2011-07-27	Available
Attachment D-1.docx	Supplementary Document	Uploaded 2011-07-27	Available
Attachment E-1.docx	Supplementary Document	Uploaded 2011-07-27	Available
Attachment C NIOSH Strategic Goals.docx	Supplementary Document	Uploaded 2011-07-26	Available
Attachment G-3.docx	Supplementary Document	Uploaded 2011-07-27	Available
Section A MSD Intervention Revised 11_1_11.docx	Supporting Statement A	Uploaded 2011-11-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198869	Early Exit Interview	Form and Instruction	New
198868	Low Back Functional Assessment	Form and Instruction	New
198867	Self-Reported General Work Environment and Health Questionnaire	Form and Instruction	New
198866	Self-Reported Specific Job Tasks and Safety Incidents Questionnaire	Form and Instruction	New
198865	Self-Reported Upper Extremity Pain Questionnaire	Form and Instruction	New
198864	Self-reported low back pain questionnaire	Form and Instruction	New
198863	Informed Consent- Low Back Functional Assessment	Form and Instruction	New
198862	Informed Consent (Questionnaire Data Collection)	Form and Instruction	New

ICR Details

OMB Control No: 0920-0907	ICR Reference No: 201108-0920-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Musculoskeletal Disorder (MSD) Intervention Effectiveness in Wholesale/ Retail Trade Operations
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: 11/17/2011
	Date Received in OIRA: 08/15/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2014	36 Months From Approved
Responses	15,701	0	0
Time Burden (Hours)	1,500	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: NIOSH proposes to conduct a study to assess the effectiveness and cost-benefit of occupational safety and health (OSH) interventions for musculoskeletal disorders (MSDs) among wholesale/ retail trade (WRT) workers. For the current study, NIOSH and the Ohio Bureau of Workers Compensation (OBWC) will collaborate on a multi-site intervention study at OBWC-insured WRT companies from 2011-2014. In overview, MSD engineering control interventions [stair-climbing, powered hand trucks (PHT) and powered truck lift gates(TLG)] will be tested for effectiveness in reducing self-reported back and upper extremity pain among 960 employees performing delivery operations in 72 WRT establishments using a prospective experimental design (multiple baselines across groups with randomization). Twenty-four OBWC-insured WRT establishments will be recruited from each of three total employee categories (<20 employees, 20-99 employees, and 100+ employees) for a total of 72 establishments with 3,240 employees. This study will determine the effectiveness of the tested MSD interventions for WRT delivery workers and enable evidence based prevention practices to be shared with the greatest audience possible. NIOSH expects to complete data collection in 2014.

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Authorizing Statute(s): PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health Act of 1970
  

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:
	76 FR 28788	05/18/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 48164	08/08/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Informed Consent (Questionnaire Data Collection)	1	Informed Consent (Questionnaire Data Collection)
Informed Consent- Low Back Functional Assessment	2	Informed Consent- Low Back Functional Assessment
Self-reported low back pain questionnaire	3	Self-reported low back pain questionnaire
Self-Reported Upper Extremity Pain Questionnaire	4	Self-Reported Upper Extremity Pain Questionnaire
Self-Reported Specific Job Tasks and Safety Incidents Questionnaire	5	Self-Reported Specific Job Tasks and Safety Incidents Questionnaire
Self-Reported General Work Environment and Health Questionnaire	6	Self-Reported General Work Environment and Health Questionnaire
Low Back Functional Assessment	7	Low Back Functional Assessment
Early Exit Interview	8	Early Exit Interview

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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	15,701	0	0	15,701	0	0
Annual Time Burden (Hours)	1,500	0	0	1,500	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 ICR.

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Annual Cost to Federal Government: $34,642

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? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 08/15/2011

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