Information Collection

Field Testing of an Instrument to Assess the Uptake and Reach

IC 253262 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-1154 NIOSH Study Evaluation Survey Field Testing of an Instrument to Assess the Uptake and Reach	Form and Instruction
0920-1154 NIOSH Study Evaluation Survey ATT2_NIOSH Survey.docx	Form and Instruction
Supporting Statement A_5-10-22 (002).docx SSA	IC Document
Supporting Statement B_5-2-22.docx SSB	IC Document
ATT1_OSH Act of 1970.pdf OSH Act of 1970	IC Document
ATT3_Recruitment_Emails.docx Att 3_Recruitment Email	IC Document
ATT4_IRB_Designation.pdf Att 4_IRB Designation	IC Document

IC Title:

Field Testing of an Instrument to Assess the Uptake and Reach

Agency IC Tracking Number:

0920-1154-22FJ

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
Form and Instruction	0920-1154				Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 550

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 Agency Discretion
Annual Number of Responses for this IC	550	550
Annual IC Time Burden (Hours)	138	138
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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

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