Information Collection

Week 1 PDM Pre-Test Survey (Control Groups)

IC 209278 under ICR 201311-0920-008 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att C-3_PDM Pre Survey.doc	Other-WORD
Att C-1_ Informed Consent Form.docx Att C-1_ Informed Consent Form	IC Document

IC Title:

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
Other-WORD			Att C-3_PDM Pre Survey.doc		Yes	No	Fillable Printable

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: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att C-1_ Informed Consent Form	Att C-1_ Informed Consent Form.docx	11/04/2013

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