Information Collection

[NIOSH] Evaluation of robot to human communication designs

IC 273435 under ICR 202502-0920-005 · OMB 0920-1441.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1441 can be found here:

2025-06-02 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1441 [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Form 0920-1441 Informed Consent [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Form 0920-1441 Robot Experience Questionnaire [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Form 0920-1441 Virtual Reality Experience Questionnaire [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Form 0920-1441 Virtual Reality Sickness Questionnaire [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Form 0920-1441 Installation/Set-Up of Virtual Reality Controller [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Form 0920-1441 Post Condition Questionnaire:Interface Modality, Safety, and Trust [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Form 0920-1441 Robot Evaluation Questionnaire [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Form 0920-1441 Demographic Survey [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Form 0920-1441 Participant Recruitment Questionnaire [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Demographic Survey (Amended) [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
Informed Consent (amended) [NIOSH] Evaluation of robot to human communication designs	Form and Instruction
0920-1441 Informed Consent Attachment B_Informed Consent Form.docx	Form and Instruction
0920-1441 Informed Consent Attachment B_Informed Consent Form.docx	Form and Instruction
0920-1441 Robot Experience Questionnaire Attachment D_Robot Experience Questionnaire.docx	Form and Instruction
0920-1441 Robot Experience Questionnaire Attachment D_Robot Experience Questionnaire.docx	Form and Instruction
0920-1441 Virtual Reality Experience Questionnaire Attachment E_Virtual Reality Experience Questionnaire.docx	Form and Instruction
0920-1441 Virtual Reality Experience Questionnaire Attachment E_Virtual Reality Experience Questionnaire.docx	Form and Instruction
0920-1441 Virtual Reality Sickness Questionnaire Attachment F_Virtual Reality Sickness Questionnaire.docx	Form and Instruction
0920-1441 Virtual Reality Sickness Questionnaire Attachment F_Virtual Reality Sickness Questionnaire.docx	Form and Instruction
0920-1441 Installation/Set-Up of Virtual Reality Controller Installation_Set-Up Virtual Reality Controller.docx	Form and Instruction
0920-1441 Installation/Set-Up of Virtual Reality Controller Installation_Set-Up Virtual Reality Controller.docx	Form and Instruction
0920-1441 Post Condition Questionnaire:Interface Modality, Safety, Attachment G_Post-Condition Questionnaire.docx	Form and Instruction
0920-1441 Post Condition Questionnaire:Interface Modality, Safety, Attachment G_Post-Condition Questionnaire.docx	Form and Instruction
0920-1441 Robot Evaluation Questionnaire Attachment H_Robot Evaluation Questionnaire.docx	Form and Instruction
0920-1441 Robot Evaluation Questionnaire Attachment H_Robot Evaluation Questionnaire.docx	Form and Instruction
0920-1441 Demographic Survey Attachment C_Demographic Survey.docx	Form and Instruction
0920-1441 Demographic Survey Attachment C_Demographic Survey.docx	Form and Instruction
0920-1441 Participant Recruitment Questionnaire Attachment J_Participant Recruitment Questionnaire.docx	Form and Instruction
0920-1441 Participant Recruitment Questionnaire Attachment J_Participant Recruitment Questionnaire.docx	Form and Instruction
Demographic Survey (Amended) Attachment C_Demographic Survey.docx	Form and Instruction
Demographic Survey (Amended) Attachment C_Demographic Survey.docx	Form and Instruction
Informed Consent (amended) Attachment B_Informed Consent Form.docx	Form and Instruction
Informed Consent (amended) Attachment B_Informed Consent Form.docx	Form and Instruction
Attachment K - OSH Act 1970_Authorizing Legislation.pdf Authorizing Legislation	IC Document
Attachment K - OSH Act 1970_Authorizing Legislation.pdf Authorizing Legislation	IC Document
Attachment J - Record of IRB Approval_Evaluation of Comm Designs.JPG IRB Determination	IC Document
Attachment J - Record of IRB Approval_Evaluation of Comm Designs.JPG IRB Determination	IC Document
Attachment I_Record of Test Subject Participation.docx Test Subject Participation Record	IC Document
Attachment I_Record of Test Subject Participation.docx Test Subject Participation Record	IC Document
2. NIOSH DSR genIC_Sampling Plan - 24-NIOSH-02 - Evaluation of R-H comm design.docx Sampling Plan	IC Document
2. NIOSH DSR genIC_Sampling Plan - 24-NIOSH-02 - Evaluation of R-H comm design.docx Sampling Plan	IC Document
Attachment A_Recruitment Flyer.docx Recruitment Flyer	IC Document
Attachment A_Recruitment Flyer.docx Recruitment Flyer	IC Document
1. NIOSH DSR genIC_Request to Debit Hours - 24-NIOSH-02 - Evaluation of R-H comm design.docx 0920-1441 GenIC Request Template - Request to Debit Hours	IC Document
1. NIOSH DSR genIC_Request to Debit Hours - 24-NIOSH-02 - Evaluation of R-H comm design.docx 0920-1441 GenIC Request Template - Request to Debit Hours	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[NIOSH] Evaluation of robot to human communication designs

Agency IC Tracking Number:

0920-1441-25CK

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1441	N/A	No		Fillable Fileable
Form and Instruction	0920-1441	N/A	No		Fillable Fileable
Form and Instruction	0920-1441	N/A	No		Fillable Fileable
Form and Instruction	0920-1441	N/A	No		Fillable Fileable
Form and Instruction	0920-1441	N/A	No		Fillable Fileable
Form and Instruction	0920-1441	N/A	No		Fillable Fileable
Form and Instruction	0920-1441	N/A	No		Fillable Fileable
Form and Instruction	0920-1441	N/A	No		Fillable Fileable
Form and Instruction	0920-1441	N/A	No		Fillable Fileable
Form and Instruction	n/a		Yes	Yes	Fillable Fileable
Form and Instruction	n/a		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 549

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	2,965	2,965
Annual IC Time Burden (Hours)	102	102
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Authorizing Legislation		12/30/2024
IRB Determination		12/30/2024
Test Subject Participation Record		12/30/2024
Sampling Plan		12/31/2024
Recruitment Flyer		01/08/2025
0920-1441 GenIC Request Template - Request to Debit Hours		01/08/2025

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

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