Early Exit Interview - Original Data Collection

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

Documents and Forms

Document Name Document Type
Early Exit Interview - Original Data Collection Form and Instruction
Early Exit Interview Attachment H-5 Early Exit Interview.docx Form and Instruction
Attachment A Authorizing Legislation.docx Authorizing Legislation IC Document

Information Collection (IC) Details

IC Title:	Early Exit Interview - Original Data Collection	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	Early Exit Interview	Attachment H-5 Early Exit Interview.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: 5	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 5 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3	-50	53
Annual IC Time Burden (Hours)	1	-3	4
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Authorizing Legislation	Attachment A Authorizing Legislation.docx	09/10/2014

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