Interventions to Reduce Shoulder MSDs in Overhead Assembly

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Work Organization Questionnaire	Form	New	Available
Standardized Nordic Questionnaire	Form	New	Available
DASH	Form	New	Available
SRQ	Form	New	Available
PAR-Q	Form	New	Available
Photo Consent	Form	New	Available
Informed Consent	Form	New	Available
Part B supporting statement -12.4.12.doc	Supporting Statement B	Uploaded 2013-01-15	Available
Attachement J.pdf	Supplementary Document	Uploaded 2013-01-15	Available
Attachment L Framing a cost benefit.docx	Supplementary Document	Uploaded 2013-01-15	Available
Attachment K Details of Interventions.docx	Supplementary Document	Uploaded 2013-01-15	Available
Attachment I Recruitment flyer.docx	Supplementary Document	Uploaded 2013-01-15	Available
Attachment E Information Security Plan.docx	Supplementary Document	Uploaded 2013-01-15	Available
Attachment D NIOSH-TEMA MOU.docx	Supplementary Document	Uploaded 2013-01-15	Available
Attachment Comments B1.docx	Supplementary Document	Uploaded 2013-01-15	Available
60day FRN.pdf	Supplementary Document	Uploaded 2013-01-15	Available
Attmt A_OSHAct.doc	Supplementary Document	Uploaded 2013-01-15	Available
Part A supporting statement 13 1 9.docx	Supporting Statement A	Uploaded 2013-01-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205869	Work Organization Questionnaire	Form	New	Work Organization Questionnaire
205868	Standardized Nordic Questionnaire for Musculoskeletal Symptoms Instrument	Form	New	Standardized Nordic Questionnaire
205867	Disabilities of the Arm Shoulder and Hand (DASH)	Form	New	DASH
205866	Shoulder Rating Questionnaire (SRQ)	Form	New	SRQ
205865	Physical Activity Readiness (PAR-Q)	Form	New	PAR-Q
205864	Consent of Photographic Image Release	Form	New	Photo Consent
205863	Informed Consent Form	Form	New	Informed Consent

ICR Details

OMB Control No: 0920-0964	ICR Reference No: 201302-0920-015
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 18524
Title: Interventions to Reduce Shoulder MSDs in Overhead Assembly
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 without change	Conclusion Date: 04/10/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/21/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2015	12 Months From Approved
Responses	4,500	0	0
Time Burden (Hours)	472	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Conducted in partnership with Toyota Motor Manufacturing Kentucky, Inc., this study will evaluate the efficacy of two intervention strategies for reducing musculoskeletal symptoms and pain in the shoulder attributable to overhead assembly work in automotive manufacturing.

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Authorizing Statute(s): PL: Pub.L. 91 - 596 20-22 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:
	77 FR 40889	07/11/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 9699	02/11/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Consent of Photographic Image Release	none	Photo Consent
Disabilities of the Arm Shoulder and Hand (DASH)	none	DASH
Informed Consent Form	none	Informed Consent
Physical Activity Readiness (PAR-Q)	none	PAR-Q
Shoulder Rating Questionnaire (SRQ)	none	SRQ
Standardized Nordic Questionnaire for Musculoskeletal Symptoms Instrument	none	Standardized Nordic Questionnaire
Work Organization Questionnaire	none	Work Organization Questionnaire

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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	4,500	0	0	4,500	0	0
Annual Time Burden (Hours)	472	0	0	472	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 data collection request.

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Annual Cost to Federal Government: $215,418

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? No

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: 02/21/2013

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