Safety and Health Information Collection Supporting Statement

SUPPORTING STATEMENT

U.S. Department of Commerce

National Institute of Standards and Technology

Safety and Health Information Collection

OMB Control No. 0693-XXXX

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary.

The National Institute of Standards and Technology (NIST) is a unique federal campus which hosts daily a range of non-federal individuals. Non-federal individuals may include NIST Associates, volunteers, students, and visitors. In order to provide these individuals with proper care and health documentation, NIST is pursuing approval of three health unit forms to be utilized for these individuals.

2. Explain how, by whom, how frequently, and for what purpose the information will be used. If the information collected will be disseminated to the public or used to support information that will be disseminated to the public, then explain how the collection complies with all applicable Information Quality Guidelines.

The NIST Health Unit utilizes three forms in which we seek approval for.

1. NIST-986: Health Record

Used as an intake form for any NIST Associate, or visitor who comes to the Health Unit to receive medical care or service. While a voluntary form, Health Unit staff request it be completed upon first visit and updated annually or upon next visit, whichever is later. The completed form is kept in the individual’s health file contained in locked filing cabinets.

2. NIST-985: Injury/Illness/Exposure Assessment

Used to document medical care provided to any NIST Associate, or visitor related to injury, illness, or exposure. The “patient” does not personally fill this form out, but information asked via interview is recorded. Completed forms are kept in the individual’s health file contained in locked filing cabinets. The forms are also faxed to appropriate NIST staff who are responsible for NIST’s OSHA recording keeping requirements related to workplace injuries and illnesses.

3. NIST-426: Audiological History

Used as part of NIST’s Hearing Protection Program for any NIST Associate. It is completed once and begins the documentation of an individual’s audiological history at NIST. The individual does not personally fill this form out, but information asked via interview is recorded. The completed form is kept in the individual’s health file contained in locked filing cabinets.

The information collected will not be disseminated to the public or used to support information that will be disseminated to the public.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological techniques or other forms of information technology.

Information is collected from individuals on paper and entered into Microsoft Office and web applications that are secured on protected NIST servers. Information may also be collected by interview as required for medical inquiries.

4. Describe efforts to identify duplication.

Web applications use central repositories whenever possible to keep duplication at a minimum and to protect the integrity of the data. NIST established an internal review process that will examine each survey or data collection effort to be conducted under the generic clearance—to prevent internal duplication of effort and to ensure that appropriate data collection instruments are developed. NIST is confident that the procedures in place ensure that there will be no duplication.

5. If the collection of information involves small businesses or other small entities, describe the methods used to minimize burden.

The collection of this information does not involve small businesses.

6. Describe the consequences to the Federal program or policy activities if the collection is not conducted or is conducted less frequently.

General health reporting information is given voluntarily and is not required in order to receive care in the NIST Health . There is no consequence to Federal program or policy activities if this collection is not conducted.

7. Explain any special circumstances that require the collection to be conducted in a manner inconsistent with OMB guidelines.

The collection will be conducted in a manner consistent with OMB guidelines.

8. Provide information of the PRA Federal Register Notice that solicited public comments on the information collection prior to this submission. Summarize the public comments received in response to that notice and describe the actions taken by the agency in response to those comments. Describe the efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

A 60-day notice soliciting comments on the information was published in the Federal Register, Vol. 82, No. 141, pp. 34484-34485, on July 25, 2017. No comments were received.

A 30-day notice was published in the Federal Register, Vol 83, No. 101, pp. 24084, on May 24, 2018.

Data collected under this information collection is typical information health care workers ask in order to provide care to individuals.

9. Explain any decisions to provide payments or gifts to respondents, other than remuneration of contractors or grantees.

There will be no payments or gifts to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for assurance in statute, regulation, or agency policy.

Data confidentiality will be protected per the Federal Information Security Modernization Act with security protections commensurate with the moderate risk level. NIST will provide Privacy Act Statements on any forms where applicable. A Privacy Act Notice will be stated on the form.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

Only relevant questions pertaining to health and safety will be utilized when an individual seeks care on the federal campus.

12. Provide an estimate in hours of the burden of the collection of information.

NIST estimates the burden hours to be 166 hours for non-federal individuals utilizing the NIST Health Unit facility:

Number of Respondents: 1000

Average Hours Per Response: 10 minutes per response.

Burden Hours: 166 hours

13. Provide an estimate of the total annual cost burden to the respondents or record-keepers resulting from the collection (excluding the value of the burden hours in

Question 12 above).

There are no known out-of-pocket costs to the respondents or record keepers (the public).

14. Provide estimates of annualized cost to the Federal government.

This information collection will involve several NIST employees that will devote a portion of their time, to plan, coordinate, administer, or monitor the overall types of individual information collections to be conducted. NIST estimates that it would involve an annual estimated total of 780 hours (15 hours per week) and an estimated cost of $87,000 per year (based on a loaded professional salary of $116 / hour).

15. Explain the reasons for any program changes or adjustments.

This is a new information collection.

16. For collections whose results will be published, outline the plans for tabulation and publication.

Collection results will not be published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons why display would be inappropriate.

The OMB Control Number, expiration date, “Notwithstanding statement”, and Privacy Act Statement will be displayed on each form.

18. Explain each exception to the certification statement.

There is no exception to the certification statement.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

Statistical methods will not be used for this collection.

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