Fire Fighters Follow-back Survey

Assessment of Occupational Injury among Fire Fighters Using a Follow-back Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1244 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-18LQ Fire Fighters Follow-back Survey Form and Instruction
0920-18LQ Fire Fighter Follow-back Survey revised Attachment C_Followback_Survey_May_2_OMB_Clean.docx Form and Instruction
Attachment D_Pre_Interview_Consent_Letter_OMB.docx Pre Interview Consent Letter IC Document

Information Collection (IC) Details

IC Title:	Fire Fighters Follow-back Survey	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
Form and Instruction	0920-18LQ	Fire Fighter Follow-back Survey revised	Attachment C_Followback_Survey_May_2_OMB_Clean.docx	NA	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 240	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	240	240
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	2,915	2,915

Documents for IC

Title	Document	Date Uploaded
Pre Interview Consent Letter	Attachment D_Pre_Interview_Consent_Letter_OMB.docx	10/10/2018

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