Information Collection

Low Back Functional Assessment

IC 198868 under ICR 201409-0920-008 · OMB 0920-0907.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 7 Low Back Functional Assessment	Form and Instruction
7 Low Back Functional Assessment Attachment I .docx	Form and Instruction
Attachment G-3.docx Attachment G-3	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	7	Low Back Functional Assessment	Attachment I .docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 192

Number of Respondents for Small Entity: 134

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-288	288
Annual IC Time Burden (Hours)	-96	96
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment G-3	Attachment G-3.docx	07/27/2011

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