Interview Protocol

Mobile Proximity Initial User Feedback

Documents and Forms

Document Name Document Type
Att F - Interview Protocol.docx Other-Interview protocol
Att I - Informed Consent Script.docx Consent IC Document

Information Collection (IC) Details

IC Title:	Interview Protocol	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-Interview protocol			Att F - Interview Protocol.docx		No		Paper Only

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	1,190	1,190

Documents for IC

Title	Document	Date Uploaded
Consent	Att I - Informed Consent Script.docx	04/12/2018

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