Information Collection

[NIOSH] Assessing Human Factors in Fire Service Fatalities and Injuries

IC 280997 under ICR 202412-0920-004 · OMB 0920-1450.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survey: Assessing Human Factors in Fire Service Fatalities and Injuries [NIOSH] Assessing Human Factors in Fire Service Fatalities and Injuries	Form and Instruction
Survey: Assessing Human Factors in Fire Service Fataliti Attachment F(a)_Survey Instrument_clean.docx	Form and Instruction
Attachment A_Survey Recruitment Email Invitation.docx Recruitment Email Invitation	IC Document
Attachment B_Survey Recruitment Informational Slide.pdf Recruitment Informational Slide	IC Document
Attachment C_Survey Email Reminder for FDs.docx Email Reminder for FDs	IC Document
Attachment D_Survey Email Reminder from NIOSH COs.docx Email Reminder for NIOSH COs	IC Document
Attachment E_Electronic Informed Consent.docx Electronic Informed Consent	IC Document
Attachment F(b)_Survey Instrument REDCap.pdf Survey Instrument REDcap	IC Document
Attachment G_IRB Exempt Determination.pdf Research Determination	IC Document
Attachment H_IRB-Approved Protocol.docx Protocol	IC Document
Attachment I_Sampling Plan_0920-1450-DSR Human Factors.docx Sampling Plan	IC Document
Attachment J_Privacy Act Determination Request.pdf PIA Request	IC Document
Attachment K_Research Electronic Data Capture REDCap 4232024.pdf Data Capture REDCap	IC Document
Attachment L_20260305_REDCAP_PTA.pdf PTA	IC Document
NIOSH genIC_Request to Debit Hours_0920-1450_OMB Passback response tc 6.15.26_final.docx GenIC Request Template	IC Document

IC Title:

Agency IC Tracking Number:

0920-26-0169

IC Status: New

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	n/a				Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,425

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,425	5,425
Annual IC Time Burden (Hours)	1,537	1,537
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment Email Invitation		06/16/2026
Recruitment Informational Slide		06/16/2026
Email Reminder for FDs		06/16/2026
Email Reminder for NIOSH COs		06/16/2026
Electronic Informed Consent		06/16/2026
Survey Instrument REDcap		06/16/2026
Research Determination		06/16/2026
Protocol		06/16/2026
Sampling Plan		06/16/2026
PIA Request		06/16/2026
Data Capture REDCap		06/16/2026
PTA		06/16/2026
GenIC Request Template		06/16/2026

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

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