[NIOSH] Heat-related Changes in Cognitive Performance

ICR 202310-0920-010

OMB: 0920-1331

Federal Form Document

Forms and Documents

Document Name	Status
Form 0920-1331 Appx O_ Exertion and Thermal Sensation Scale (M/FF/CW) Form	Modified
Form 0920-1331 Appx N_ Release of Information (HIPPA) (M/FF/CW) Form	Modified
Form 0920-1331 Appx M_ Consent Form Environment Chamber (M/FF/CW) Form and Instruction	Modified
Form 0920-1331 Appx L Consent (Field component) _Miners Form and Instruction	Modified
Form 0920-1331 Appx G_Health Screen Questionnaire -- Environment Chamber (M/FF/CW) Form	Modified
Form 0920-1331 Appx F_Physcal Examination (M/FF/CW) Form	Modified
Form 0920-1331 Appx C_Initial Participant Questionnaire: Field (Health screening) Form and Instruction	Modified
Appendix Q IRB amendment approval.pdf Supplementary Document	2024-02-07
PIA.pdf Supplementary Document	2024-01-30
Appendix B 60 day FRN.pdf Supplementary Document	2024-02-27
Appendix A Federal Mine Safety and Health Act.docx Supplementary Document	2020-08-11
SMRD_Heat stress_SSB.docx Supporting Statement B	2024-01-30
SSA_SMRD_Heat Stress_02-27-24.docx Supporting Statement A	2024-02-27

IC Document Collections

IC ID	Document Title	Status
243426	Cognitive test: N-back -- no form (M/FF/CW) Instruction	Unchanged
243425	Consent - Research Study (PVT Cognitive Test) - Field (M/FF/CW) Instruction	Modified
243424	Appx O_ Exertion and Thermal Sensation Scale (M/FF/CW) Form	Modified
243423	Appx N_ Release of Information (HIPPA) (M/FF/CW) Form	Modified
243422	Fingerstick blood sample for point of care testing Instruction	Unchanged
243421	Fitting of Chest Strap (M/FF/CW) Instruction	Unchanged
243420	Ingestion of Temperature Pill (M/FF/CW) Instruction	Modified
243419	Appx K_Field Recruitment Script (PVT Cognitive Test) _Miner Instruction	Modified
243413	Fitting of Chest Strap (M) Instruction	Unchanged
243412	Consent Form - (Ingestion of Temperature Pill (M)) Instruction	Modified
243410	Appx M_ Consent Form Environment Chamber (M/FF/CW) Form and Instruction	Modified
243407	Appx L Consent (Field component) _Miners Form and Instruction	Modified
243405	Appx I_ Pre-Test Questionnaire (M/FF/CW) Other-App (WORD)	Unchanged
243404	Appx H_PANAS sleepiness fatigue (M/FF/CW) Other-WORD	Unchanged
243403	Appx G_Health Screen Questionnaire -- Environment Chamber (M/FF/CW) Form	Modified
243402	Appx F_Physcal Examination (M/FF/CW) Form	Modified
243135	Appx E -Pre-Shift Questionnaire on Heat Stress (App) Miners Other-App (WORD)	Modified
243132	Appx D - Questionnaire on Heat Stress (App) Miners-- Shift for field Other-App (WORD)	Modified
243129	Appx C_Initial Participant Questionnaire: Field (Health screening) Form and Instruction	Modified