Information Collection

Shoulder Rating Questionnaire (SRQ)

IC 205866 under ICR 201302-0920-015 · OMB 0920-0964.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0964 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Shoulder Rating Questionnaire (SRQ)	Form
SRQ Attachment G2 Shoulder Rating Questionnaire.8.13.12docx.docx	Form

IC Title:

Shoulder Rating Questionnaire (SRQ)

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	none	SRQ	Attachment G2 Shoulder Rating Questionnaire.8.13.12docx.docx		Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: 09-20-0118 Study at Work Sites Where Agents Suspected of Being Occupational Hazards Exist

FR Citation: 51 FR 42469

Number of Respondents: 125

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	1,250	1,250
Annual IC Time Burden (Hours)	83	83
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.