Information Collection

Self-reported low back pain questionnaire

IC 198864 under ICR 201108-0920-004 · OMB 0920-0907.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0907 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Self-reported low back pain questionnaire Form and Instruction
3 Self-reported low back pain questionnaire Attachment H-1 .docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Self-reported low back pain questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Self-reported low back pain questionnaire	Attachment H-1 .docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 960	Number of Respondents for Small Entity: 672

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

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,320	4,320
Annual IC Time Burden (Hours)	360	360
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.