Biographical Information

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/xxxx

Attachment E: Biographical Information

Privacy Act Statement:

This data collection is authorized by the Occupational Safety and Health Act of 1970. Disclosure of this information is voluntary and you may withdraw your consent and your participation in this study at any time without penalty or loss of benefits to which you are otherwise entitled. There are no effects on the individual for not providing any or all parts of the requested information. NIOSH will use this information to redesign LEO cruiser cabs and personal protective gear (such as body armors). More specifically, the data will be used in defining the adjustment range of seats and restraint systems and other safety features of the cab as well as in specifying improved sizing systems for protective gear. This information will be used by and disclosed to NIOSH personnel and contractors or other agents who need the information to assist in activities related to the redesign of LEO cruiser cabs and personal protective gear. The results of the study in a summary format will be disseminated to police vehicle manufacturers, manufacturers of law enforcement officer (LEO) safety equipment, and state police organizations. Additional dissemination of results will be reported in peer-reviewed journals and other transportation safety forums. All data shared will be de-identified prior to dissemination. This activity is covered under the Privacy Act System of Records Notice (SORN) Records of Subjects in Certification, Testing, Studies of Personal Protective Devices, and Accident Investigations, Privacy Act System Notice 09-20-0159, which can be found here: https://www.cdc.gov/SORNnotice/09-20-0159.htm.

Burden Statement:

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Participant Number

Sex: (Circle One) Male Female

Please indicate your race or ethnic background. Are you….?

SELECT ONE

Ethnicity:

□ Hispanic or Latino

□ Not Hispanic or Latino

SELECT ONE OR MORE

Race:

□ White □ Asian □ American Indian or Alaska Native

□ Black or African American □ Native Hawaiian or Other Pacific Islander

Birth Date (mm-yyyy)

Occupation

Years of Service at the Current Occupation

Exam Location

Exam Date (mm-dd-yyyy)

Body Height (cm) 1” = 2.54 cm

Body weight (kg) 1 lb =0.4545 kg

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