Information Collection Request

[NIOSH] Heat-related Changes in Cognitive Performance

ICR 202310-0920-010 · OMB 0920-1331 · Received in OIRA

Forms and Documents

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

IC Document Collections

IC ID	Collection	Type	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

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CDC
OMB Control No	0920-1331
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202008-0920-005
Agency Tracking No	0920-1331
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31