A Longitudinal Examination of Mental and Physical Health among Police Associated with COVID–19

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920- Serological Sample	Form	Unchanged	Available
Form 0920- Att D18- Serological Sample	Form	Unchanged	Available
Form 0920- Civil Unrest	Form	Unchanged	Available
Form 0920- Att D17- Civil Unrest	Form	Unchanged	Repair queued
Form 0920- COVID- Round2	Form	Unchanged	Available
Form 0920- Att D16- COVID19- Round 2	Form	Unchanged	Repair queued
Form 0920- COVID- Round 2	Form	Unchanged	Available
Form 0920- Att D15- COVID- Round 1	Form	Unchanged	Available
Form 0920- Beck Hopelessness	Form	Unchanged	Available
Form 0920- Att D14- Beck Hopelessness	Form	Unchanged	Repair queued
Form 0920- Att D13- Beck Depression	Form	Unchanged	Available
Form 0920- Att D13- Beck Depression	Form	Unchanged	Available
Form 0920- Pittsburgh Sleep Quality Index	Form	Unchanged	Available
Form 0920- Att D12- Pittsburgh Sleep Quality Index	Form	Unchanged	Available
Form 0920- Beck Anxiety	Form	Unchanged	Available
Form 0920- Att D11- Beck Anxiety	Form	Unchanged	Repair queued
Form 0920 Connoe Scale	Form	Unchanged	Available
Form 0920 Att D10- Connor-Davidson Resiliency Scale	Form	Unchanged	Repair queued
Form 0920 Posttraumatic Stress Disorder -5	Form	Unchanged	Available
Form 0920 Att D9- PTSD	Form	Unchanged	Repair queued
Form 0920 Fatigue Scale	Form	Unchanged	Available
Form 0920 Att D8- Fatigue Scale	Form	Unchanged	Repair queued
Form 0920- Maslach Burnout	Form	Unchanged	Available
Form 0920- Att D7- Maslach Burnout	Form	Unchanged	Repair queued
Form 0920 Organizational Support Scale	Form	Unchanged	Available
Form 0920 Att D6- Org Support	Form	Unchanged	Repair queued
Form 0920- Brief Cope	Form	Unchanged	Available
Form 0920- Att D5_Brief Cope	Form	Unchanged	Repair queued
Form 0920- Centers for Epidemiological Studies Depression	Form	Unchanged	Available
Form 0920- Att D4- Centers for Epidemiologic Studies Depression Scale	Form	Unchanged	Repair queued
Form 0920- Eligibility Screening	Form	Unchanged	Available
Form 0920- Att H1_Eligibility Screening	Form	Unchanged	Repair queued
Form 0920- Spielberger Stress Survey	Form	Unchanged	Available
Form 0920- Att D3- Spielberger Stress Survey	Form	Unchanged	Repair queued
Form 0920 Medical History	Form	Unchanged	Available
Form 0920 Att D2- Medical History	Form	Unchanged	Repair queued
Form 0920 Personal History	Form	Unchanged	Repair queued
Form 0920 Att D1- Personal History	Form	Unchanged	Repair queued
Change Request Memo 12OCT2021.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-10-12	Repair queued
Appendix F2 NIOSH HSRB_non_exempt.pdf	Supplementary Document	Uploaded 2021-07-28	Repair queued
Appendix F1 UB IRB.docx	Supplementary Document	Uploaded 2021-07-28	Repair queued
Appendix E UB Consent Form.docx	Supplementary Document	Uploaded 2021-07-28	Repair queued
Appendix C Examination Components.docx	Supplementary Document	Uploaded 2021-07-02	Repair queued
Appendix B _60dy2121CG.FRN.pdf	Supplementary Document	Uploaded 2021-07-02	Repair queued
Appendix A.docx	Supplementary Document	Uploaded 2021-07-02	Repair queued
Statement B_revised 092921.docx	Supporting Statement B	Uploaded 2021-10-12	Repair queued
Statement A_revised 92921.docx	Supporting Statement A	Uploaded 2021-10-12	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
248601	Att D19- Salivary Cortisol collection	Other-	Unchanged
248600	Att D18- Serological Sample	Form	Unchanged	Serological Sample
248600	Att D18- Serological Sample	Form	Unchanged
248599	Att D17- Civil Unrest	Form	Unchanged	Civil Unrest
248599	Att D17- Civil Unrest	Form	Unchanged
248598	Att D16- COVID19- Round 2	Form	Unchanged	COVID- Round2
248598	Att D16- COVID19- Round 2	Form	Unchanged
248597	Att D15- COVID- Round 1	Form	Unchanged	COVID- Round 2
248597	Att D15- COVID- Round 1	Form	Unchanged
248596	Att D14- Beck Hopelessness	Form	Unchanged	Beck Hopelessness
248596	Att D14- Beck Hopelessness	Form	Unchanged
248595	Att D13- Beck Depression	Form	Unchanged	Att D13- Beck Depression
248595	Att D13- Beck Depression	Form	Unchanged
248594	Att D12- Pittsburgh Sleep Quality Index	Form	Unchanged	Pittsburgh Sleep Quality Index
248594	Att D12- Pittsburgh Sleep Quality Index	Form	Unchanged
248592	Att D11- Beck Anxiety	Form	Unchanged	Beck Anxiety
248592	Att D11- Beck Anxiety	Form	Unchanged
248589	Att D10- Connor-Davidson Resiliency Scale	Form	Unchanged	Connoe Scale
248589	Att D10- Connor-Davidson Resiliency Scale	Form	Unchanged
248588	Att D9- PTSD	Form	Unchanged	Posttraumatic Stress Disorder -5
248588	Att D9- PTSD	Form	Unchanged
248587	Att D8- Fatigue Scale	Form	Unchanged	Fatigue Scale
248587	Att D8- Fatigue Scale	Form	Unchanged
248586	Att D7- Maslach Burnout	Form	Unchanged	Maslach Burnout
248586	Att D7- Maslach Burnout	Form	Unchanged
248585	Att D6- Org Support	Form	Unchanged	Organizational Support Scale
248585	Att D6- Org Support	Form	Unchanged
248582	Att D5_Brief Cope	Form	Unchanged	Brief Cope
248582	Att D5_Brief Cope	Form	Unchanged
248581	Att D4- Centers for Epidemiologic Studies Depression Scale	Form	Unchanged	Centers for Epidemiological Studies Depression
248581	Att D4- Centers for Epidemiologic Studies Depression Scale	Form	Unchanged
248580	Att H1_Eligibility Screening	Form	Unchanged	Eligibility Screening
248580	Att H1_Eligibility Screening	Form	Unchanged
248579	Att H_Introduction Letter	Other-word	Unchanged
248575	Att G_Letter of Invitation	Other-WORD	Unchanged
248340	Att D3- Spielberger Stress Survey	Form	Unchanged	Spielberger Stress Survey
248340	Att D3- Spielberger Stress Survey	Form	Unchanged
248339	Att D2- Medical History	Form	Unchanged	Medical History
248339	Att D2- Medical History	Form	Unchanged
248338	Att D1- Personal History	Form	Unchanged	Personal History
248338	Att D1- Personal History	Form	Unchanged

ICR Details

OMB Control No: 0920-1350	ICR Reference No: 202110-0920-005
Status: Historical Active	Previous ICR Reference No: 202106-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-21CG
Title: A Longitudinal Examination of Mental and Physical Health among Police Associated with COVID–19
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/13/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/12/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2024	09/30/2024	09/30/2024
Responses	6,580	0	6,580
Time Burden (Hours)	596	0	596
Cost Burden (Dollars)	0	0	0

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Abstract: The overarching goal of this study is to evaluate the longitudinal consequences of the COVID-19 pandemic on the mental and physical health of police officers. This data will consist of markers of disease such as blood pressure, measurement of lipids, glucose, and insulin, measurement of body fat and salivary cortisol. Psychosocial factors detrimental to health such as perceived stress, work stress, depression, as well as protective factors (e.g. resiliency and coping) will also be examined. This Non-Substantive Change Request is submitted to modify the discussion of incentives in Supporting Statement Part A and the Consent Form so that it matches incentive amounts in Supporting Statement Part B. The Change Request also revises the language in Supporting Statement Parts A and B describing the incentives for this study. Per OMB guidance, NIOSH has removed the term “token of appreciation.” There is no change to the overall burden or instruments associated with the approved study.

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Authorizing Statute(s): US Code: 29 USC 699 Name of Law: the Occupational Safety and Health Act
  

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 7095	01/26/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 35295	07/02/2021
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 22

table that charts list of burden

IC Title	Form No.	Form Name
Att D1- Personal History	0920	Personal History
Att D2- Medical History	0920	Medical History
Att D3- Spielberger Stress Survey	0920-	Spielberger Stress Survey
Att D10- Connor-Davidson Resiliency Scale	0920	Connoe Scale
Att D11- Beck Anxiety	0920-	Beck Anxiety
Att D12- Pittsburgh Sleep Quality Index	0920-	Pittsburgh Sleep Quality Index
Att D13- Beck Depression	0920-	Att D13- Beck Depression
Att D14- Beck Hopelessness	0920-	Beck Hopelessness
Att D15- COVID- Round 1	0920-	COVID- Round 2
Att D16- COVID19- Round 2	0920-	COVID- Round2
Att D17- Civil Unrest	0920-	Civil Unrest
Att D18- Serological Sample	0920-	Serological Sample
Att D19- Salivary Cortisol collection
Att D4- Centers for Epidemiologic Studies Depression Scale	0920-	Centers for Epidemiological Studies Depression
Att D5_Brief Cope	0920-	Brief Cope
Att D6- Org Support	0920	Organizational Support Scale
Att D7- Maslach Burnout	0920-	Maslach Burnout
Att D8- Fatigue Scale	0920	Fatigue Scale
Att D9- PTSD	0920	Posttraumatic Stress Disorder -5
Att G_Letter of Invitation
Att H1_Eligibility Screening	0920-	Eligibility Screening
Att H_Introduction Letter

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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	6,580	6,580	0	0	0	0
Annual Time Burden (Hours)	596	596	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: This is a new data collection

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Annual Cost to Federal Government: $796,355

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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.     No

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.     No

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: 10/12/2021

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