Safety and Health Information Collection

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form NIST-986 Health Record	Form	Modified	Available
Form NIST-986 Health Record	Form	Modified	Repair queued
Form NIST-985 Injury / Illness / Exposure Assessment	Form	Modified	Available
Form NIST-985 Injury / Illness / Exposure Assessment	Form	Modified	Repair queued
Form NIST-426 Audiological History	Form	Modified	Repair queued
Form NIST-426 Audiological History	Form	Modified	Repair queued
0693-0080 OSHE Supporting Statement_Final 2021.docx	Supporting Statement A	Uploaded 2021-07-27	Repair queued
SORN COMMERCE DEPT.18.pdf	Supplementary Document	Uploaded 2021-07-26	Repair queued
Health unit Privacy Act Statement.docx	Supplementary Document	Uploaded 2021-07-26	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
231570	Health Record	Form	Modified	Health Record
231570	Health Record	Form	Modified
231569	Injury / Illness / Exposure Assessment	Form	Modified	Injury / Illness / Exposure Assessment
231569	Injury / Illness / Exposure Assessment	Form	Modified
231567	Audiological History	Form	Modified	Audiological History
231567	Audiological History	Form	Modified

ICR Details

OMB Control No: 0693-0080	ICR Reference No: 202107-0693-003
Status: Historical Active	Previous ICR Reference No: 201805-0693-001
Agency/Subagency: DOC/NIST	Agency Tracking No: MO
Title: Safety and Health Information Collection
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/30/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/27/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2024	36 Months From Approved	08/31/2021
Responses	999	0	999
Time Burden (Hours)	168	0	168
Cost Burden (Dollars)	0	0	0

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Abstract: 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 renewal of approval of three health unit forms to be utilized for these individuals.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 20366	04/19/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 40197	07/27/2021
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Audiological History	NIST-426	Audiological History
Health Record	NIST-986	Health Record
Injury / Illness / Exposure Assessment	NIST-985	Injury / Illness / Exposure Assessment

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	999	999	0	0	0	0
Annual Time Burden (Hours)	168	168	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $87,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/27/2021

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