Information Collection

Att 9 Pre- and Post-Test Session Participant Questionnaire and Examination

IC 263389 under ICR 202410-0920-021 · OMB 0920-0109.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0109 Att 9 Pre- and Post-Test Session Participant Questionnaire and Examination	Form
Form 0920-0109 Pre- and Post-Test Session Participant Questionnaire and Examination Att 9 Pre- and Post-Test Session Participant Questionnaire and Examination	Form
0920-0109 Pre- and Post-Test Session Participant Questionnaire and Atch_9_Questionnaire.pdf	Form
0920-0109 Pre- and Post-Test Session Participant Questionnaire and Atch_9_Questionnaire.pdf	Form
Atch_9a_InformedConsentForm.docx Consent Form	IC Document
Atch_9a_InformedConsentForm.docx Consent Form	IC Document
Atch_9_InformedConsentForm (Clean).docx Consent to be in a NIOSH Study_18OCT2024	IC Document
Atch_9_InformedConsentForm (Clean).docx Consent to be in a NIOSH Study_18OCT2024	IC Document

IC Title:

Agency IC Tracking Number:

0920-0109

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	0920-0109				Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	40
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form		11/14/2023
Consent to be in a NIOSH Study_18OCT2024		10/18/2024

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

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