Information Collection

Low Back Functional Assessment

IC 198868 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⚠️ Notice: This information collection may be referencing outdated material.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 7 Low Back Functional Assessment	Form and Instruction
7 Low Back Functional Assessment Attachment I .docx	Form and Instruction
Attachment G-3.docx Attachment G-3	IC Document

IC Title:

Low Back Functional Assessment

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	7	Low Back Functional Assessment	Attachment I .docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 192

Number of Respondents for Small Entity: 134

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	288	288
Annual IC Time Burden (Hours)	96	96
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment G-3	Attachment G-3.docx	07/27/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.