Information Collection

Self-Reported Low Back Pain Questionnaire - Original Data Collection

IC 198864 under ICR 201409-0920-008 · OMB 0920-0907.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Self-Reported Low Back Pain Questionnaire - Original Data Collection	Form and Instruction
Self-Reported Low Back Pain Questionnaire Attachment H-1 Self Report Low Back Pain.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	None	Self-Reported Low Back Pain Questionnaire	Attachment H-1 Self Report Low Back Pain.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 87

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	305	-4,015	4,320
Annual IC Time Burden (Hours)	25	-335	360
Annual IC Cost Burden (Dollars)	0	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.