Information Collection

Self-Reported Upper Extremity Pain Questionnaire

IC 198865 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 4 Self-Reported Upper Extremity Pain Questionnaire	Form and Instruction
4 Self-Reported Upper Extremity Pain Questionnaire Attachment H-2 .docx	Form and Instruction

IC Title:

Self-Reported Upper Extremity Pain Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4	Self-Reported Upper Extremity Pain Questionnaire	Attachment H-2 .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 %

table that charts list of burden
	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

table that charts IC Documents
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.