Information Collection

Formative Research to Inform an Intervention to Improve Early Detection and Surveillance of Pneumoconiosis in US Coal Miners

IC 238392 under ICR 201610-0920-009 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_B_Interview Protocol.docx	Other-Interview guide
Attachment_D_FG_Protocol.docx	Other-Focus group guide
Interview demographic survey Attachment_C_Interview_Demographics.docx	Form
Focus group demographic survey Attachment_E_FG_Demographics.docx	Form
Interview sign-up Attachment_G_Interview_Sign-Up.docx	Form
Attachment_A_Federal Mine Safety & Health 1977.pdf Authorizing legislation	IC Document
Support Statement A_v4_clean.docx Supporting Statement A	IC Document
Supporting Statement B.docx Supporting Statement B	IC Document
Attachment_F_Interview_Recruitment.docx Interview recruitment script	IC Document
Attachment_H_FG_Recruitment.docx Focus group recruitment script	IC Document
Attachment_I_IRBDetermination.pdf Research determination	IC Document
Attachment_K_Interview_Consent.docx Interview consent	IC Document
Attachment_J_FG_Consent.docx Focus group consent	IC Document
Draft Generic Clearance Submission-final.docx genIC Request for Approval	IC Document

IC Title:

Formative Research to Inform an Intervention to Improve Early Detection and Surveillance of Pneumoconiosis in US Coal Miners

Agency IC Tracking Number:

0920-1154-19BSR

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Interview guide			Attachment_B_Interview Protocol.docx	Yes	No	Paper Only
Form	none	Interview demographic survey	Attachment_C_Interview_Demographics.docx	Yes	No	Paper Only
Other-Focus group guide			Attachment_D_FG_Protocol.docx	Yes	No	Paper Only
Form	none	Focus group demographic survey	Attachment_E_FG_Demographics.docx	Yes	No	Paper Only
Form	none	Interview sign-up	Attachment_G_Interview_Sign-Up.docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 276

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	276	276
Annual IC Time Burden (Hours)	124	124
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Authorizing legislation	Attachment_A_Federal Mine Safety & Health 1977.pdf	11/07/2019
Supporting Statement A	Support Statement A_v4_clean.docx	11/07/2019
Supporting Statement B	Supporting Statement B.docx	11/07/2019
Interview recruitment script	Attachment_F_Interview_Recruitment.docx	11/07/2019
Focus group recruitment script	Attachment_H_FG_Recruitment.docx	11/07/2019
Research determination	Attachment_I_IRBDetermination.pdf	11/07/2019
Interview consent	Attachment_K_Interview_Consent.docx	11/07/2019
Focus group consent	Attachment_J_FG_Consent.docx	11/07/2019
genIC Request for Approval	Draft Generic Clearance Submission-final.docx	11/07/2019

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