Interventions to Reduce Shoulder MSDs in Overhead Assembly

Forms and Documents

Document Name	Status
Work Organization Questionnaire Form	New
Standardized Nordic Questionnaire for Musculoskeletal Symptoms Instrument Form	New
Disabilities of the Arm Shoulder and Hand (DASH) Form	New
Shoulder Rating Questionnaire (SRQ) Form	New
Physical Activity Readiness (PAR-Q) Form	New
Consent of Photographic Image Release Form	New
Informed Consent Form Form	New
Part B supporting statement -12.4.12.doc Supporting Statement B	2013-01-15
Attachement J.pdf Supplementary Document	2013-01-15
Attachment L Framing a cost benefit.docx Supplementary Document	2013-01-15
Attachment K Details of Interventions.docx Supplementary Document	2013-01-15
Attachment I Recruitment flyer.docx Supplementary Document	2013-01-15
Attachment E Information Security Plan.docx Supplementary Document	2013-01-15
Attachment D NIOSH-TEMA MOU.docx Supplementary Document	2013-01-15
Attachment Comments B1.docx Supplementary Document	2013-01-15
60day FRN.pdf Supplementary Document	2013-01-15
Attmt A_OSHAct.doc Supplementary Document	2013-01-15
Part A supporting statement 13 1 9.docx Supporting Statement A	2013-01-15

IC Document Collections

IC ID	Document Title	Status
205869	Work Organization Questionnaire Form	New
205868	Standardized Nordic Questionnaire for Musculoskeletal Symptoms Instrument Form	New
205867	Disabilities of the Arm Shoulder and Hand (DASH) Form	New
205866	Shoulder Rating Questionnaire (SRQ) Form	New
205865	Physical Activity Readiness (PAR-Q) Form	New
205864	Consent of Photographic Image Release Form	New
205863	Informed Consent Form Form	New

ICR Details

OMB Control No: 0920-0964	ICR Reference No: 201302-0920-015
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 18524
Title: Interventions to Reduce Shoulder MSDs in Overhead Assembly
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/10/2013
	Date Received in OIRA: 02/21/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2015	12 Months From Approved
Responses	4,500	0	0
Time Burden (Hours)	472	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Conducted in partnership with Toyota Motor Manufacturing Kentucky, Inc., this study will evaluate the efficacy of two intervention strategies for reducing musculoskeletal symptoms and pain in the shoulder attributable to overhead assembly work in automotive manufacturing.

---

Authorizing Statute(s): PL: Pub.L. 91 - 596 20-22 Name of Law: Occupational Safety and Health Act of 1970
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 40889	07/11/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 9699	02/11/2013
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
Physical Activity Readiness (PAR-Q)	none	PAR-Q
Informed Consent Form	none	Informed Consent
Shoulder Rating Questionnaire (SRQ)	none	SRQ
Consent of Photographic Image Release	none	Photo Consent
Disabilities of the Arm Shoulder and Hand (DASH)	none	DASH
Standardized Nordic Questionnaire for Musculoskeletal Symptoms Instrument	none	Standardized Nordic Questionnaire
Work Organization Questionnaire	none	Work Organization Questionnaire

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,500	0	0	4,500	0	0
Annual Time Burden (Hours)	472	0	0	472	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new data collection request.

---

Annual Cost to Federal Government: $215,418

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/21/2013

---