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Federal forms, ICRs, and supporting documents

Information Collection

Seat belt use among workers who drive as part of their job: what's not "clicking"?

IC 249357 under ICR 201912-0920-003 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment B _Worker Interview Guide.docx	Other-WORD
Attachment C_Supervisor_Managers Focus Group Guide.docx	Other-WORD
Attachment F_Information about the study for workers and recruitment script.docx	Other-WORD
Attachment G_Information about the study for supervisors_managers and recruitment script.docx	Other-WORD
Supporting_Statement_A_ SB study 09072021.docx SSA	IC Document
Supporting_Statement_B_SB study 09072021.docx SSB	IC Document
Attachment A- OSH Act.docx OSH Act	IC Document
Attachment D_Worker recruitment materials.docx Worker Recruitment Materials (English version)	IC Document
Attachment E_Manager_supervisor recruitment materials.docx Manager/Supervisor Recruitment Materials	IC Document
Attachment H_Worker consent form.docx Worker Consent Form	IC Document
Attachment I_Manager_Supervisor consent form.docx Supervisor/Manager Consent Form	IC Document
Attachment J_IRB approval letter.pdf IRB Approval Letter	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Seat belt use among workers who drive as part of their job: what's not "clicking"?

Agency IC Tracking Number:

0920-1154-21IB

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD					No		Paper Only
Other-WORD					No		Paper Only
Other-WORD					No		Paper Only
Other-WORD					No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	60	0	60	0	0	0
Annual IC Time Burden (Hours)	140	0	140	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA		09/16/2021
SSB		09/20/2021
OSH Act		09/20/2021
Worker Recruitment Materials (English version)		09/20/2021
Manager/Supervisor Recruitment Materials		09/20/2021
Worker Consent Form		09/20/2021
Supervisor/Manager Consent Form		09/20/2021
IRB Approval Letter		09/20/2021

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

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