Information Collection

Appx L Consent (Field component) _Miners

IC 243407 under ICR 202310-0920-010 · OMB 0920-1331.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1331 Appx L Consent (Field component) _Miners	Form and Instruction
0920-1331 Consent to be in a Research Study Health-related changes Appendix L Consent form field study.docx	Form and Instruction
0920-1331 Consent to be in a Research Study Health-related changes Appendix L Consent form field study.docx	Form and Instruction
Appendix K Recruitment Script - Field.docx Appx K_ Field Recruitment Script	IC Document
Appendix K Recruitment Script - Field.docx Appx K_ Field Recruitment Script	IC Document

IC Title:

Agency IC Tracking Number:

0920-1331

Is this a Common Form? No

IC Status: Modified

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	0920-1331	Consent to be in a Research Study Health-related changes in cognitive performance Field component.	Appendix L Consent form field study.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

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	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appx K_ Field Recruitment Script	Appendix K Recruitment Script - Field.docx	10/30/2023

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