Low Back Functional Assessment

Musculoskeletal Disorder (MSD) Intervention Effectiveness in an Insurer-Supported Engineering Control Program

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Low Back Functional Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	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 %

	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

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.