0920-23HM Actigraphy

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

National Institute for Occupational Safety and Health (NIOSH)

Assessing Fatigue and Fatigue Management in U.S. Onshore Oil and Gas Extraction

Project Officers: Alejandra Ramirez-Cardenas and Imelda Wong

Statement of Actiwatch Return

Actiwatch:

For the data collection period of this study NIOSH will provide you with an Actiwatch (a wristwatch-like device that measures motion), teach you how to use it, and ask you to voluntarily (?) wear it during the data collection period. Because the Actiwatch is research equipment and the data recorded can only be downloaded with specialized software, we would greatly appreciate its safe return.

Return of Actiwatch Wristwatch:

Please return the Actiwatch to the NIOSH study team or your health and safety supervisor upon the completion of the data collection period or within one week of deciding to end participation in this study. If the Actiwatch is not returned within this timeframe, the project officers will contact you via telephone to coordinate the return of the Actiwatch.

If you have any questions, concerns, or problems please call the Principal Officer Alejandra Ramirez-Cardenas at 303-236-5957 or email [email protected].

I understand the above statement and will return the Actiwatch.

_____________________________________ ______________________________

Printed Name Phone number

_____________________________________ Actiwatch serial #_______________

Date

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-XXXX).