NIOSH Model Informed Consent Form

Assessing and Evaluating Human Systems Integration Needs in Mining

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0981 can be found here:

Documents and Forms

Document Name Document Type
NIOSH Model Informed Consent Form Form and Instruction
NIOSH Model Informed Consent Form Appendix Q_NIOSHModelInformedConsentForm.doc Form and Instruction

Information Collection (IC) Details

IC Title:	NIOSH Model Informed Consent Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	None	NIOSH Model Informed Consent Form	Appendix Q_NIOSHModelInformedConsentForm.doc		Yes	No	Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 285	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	285	285
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.