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

CDC/ATSDR Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.