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App I_Final Survey for Boot Wear Evaluation
ICR 201906-0920-012 · OMB 0920-1125 · Object 92835801.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | App I_Final Survey for Boot Wear Evaluation |
| Author | Foley, Tamekia (CDC/NIOSH/OD) |
| Last Modified By | Writer |
| File Modified | 2016-05-17 |
| File Created | 2026-09-20 |
| Conversion State | complete |
Extracted Text
Appendix I
Final Survey for Boot Wear Evaluation
Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx
Final Survey for Boot Wear Evaluation
Assigned participant ID: __________
Date: ____ / _____ / 20 _____
Recorded by: MFN / MEN / PD / WP / JP / AM / JM
Picture of boots taken: Yes / No Scan of boots taken: Yes / No
1. What is your reason for ending this study?
My company decided that I needed to replace my boots.
This is the normal time for company-wide/site wide/crew wide replacement
I decided I no longer wanted to participate.
I decided that the boots had reached the end of their usable life
How did you decide the boots had reached the end of their usable life?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. Were your boots returned to the researcher? Yes / No
3. If you had a choice of wearing this exact make and model of boot again, would you?
Yes, I hope to get these boots again.
Yes, I would wear them again.
No, I would not wear them again.
Please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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).