Spanish Trench Safety CD-ROM

CDC and ATSDR Health Message Testing System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Document Name Document Type
Spanish Trench Safety CD-ROM Form
Survey - Spanish Attachment B-Survey Items Spanish-Flynn_4-11-14.docx Form
Recruitment Script Attachment D-Recruitment Script Spanish-Flynn_4-14-14.docx Form
HMTS_Expedited_Review_Form_4-11-14.pdf HMT Request Template IC Document
Attachment C-Survey Items English-Flynn_4-14-14.docx Survey - English IC Document
Attachment E-Recruitment Script English-Flynn_4-14-14.docx Recruitment - English IC Document
Attachment A-Study Protocol-Flynn_4-14-14.docx Study Protocol IC Document
Attachment F - Informed Consent_4-14-14.docx Informed Consent IC Document
Attachment G-IncentiveJustification-Flynn_4-14-14.docx Incentive Justification IC Document

Information Collection (IC) Details

IC Title:	Spanish Trench Safety CD-ROM	Agency IC Tracking Number:	14VJ

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	none	Survey - Spanish	Attachment B-Survey Items Spanish-Flynn_4-11-14.docx		Yes	No	Paper Only
Form	none	Recruitment Script	Attachment D-Recruitment Script Spanish-Flynn_4-14-14.docx		Yes	No	Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HMT Request Template	HMTS_Expedited_Review_Form_4-11-14.pdf	04/17/2014
Survey - English	Attachment C-Survey Items English-Flynn_4-14-14.docx	04/17/2014
Recruitment - English	Attachment E-Recruitment Script English-Flynn_4-14-14.docx	04/17/2014
Study Protocol	Attachment A-Study Protocol-Flynn_4-14-14.docx	04/17/2014
Informed Consent	Attachment F - Informed Consent_4-14-14.docx	04/17/2014
Incentive Justification	Attachment G-IncentiveJustification-Flynn_4-14-14.docx	04/17/2014

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