Measuring Well-Being for Total Worker Health®

Forms and Documents

Document Name	Status
National Worker Well-being Survey Form	New
Worker Well-Being Supporting Statement B_03_7_18.docx Supporting Statement B	2018-03-13
Worker Well-Being Supporting Statement A 03_7_18.docx Supporting Statement A	2018-03-13
Att. J.docx Supplementary Document	2018-03-12
Att. I Domain and subdomains table.docx Supplementary Document	2018-03-12
Att. G References.docx Supplementary Document	2018-03-12
Att F IRB.pdf Supplementary Document	2018-03-12
Att E Recruitment and reminder text_10042016.docx Supplementary Document	2018-03-12
Att C Consent Form_Revised.rtf Supplementary Document	2018-03-12
Att B1 60-day FRN.pdf Supplementary Document	2018-03-12
Att A LegisAuth.pdf Supplementary Document	2018-03-12

IC Document Collections

IC ID	Document Title	Status
230660	National Worker Well-being Survey Form	New

ICR Details

OMB Control No: 0920-1234	ICR Reference No: 201803-0920-006
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-17BM
Title: Measuring Well-Being for Total Worker Health®
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: 06/01/2018
	Date Received in OIRA: 03/13/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	12 Months From Approved
Responses	1,025	0	0
Time Burden (Hours)	342	0	0
Cost Burden (Dollars)	7,937	0	0

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Abstract: Organizations work to cultivate well-being to improve employee safety, health, and well-being. To do that, worker well-being it must be defined and measured. This project tests a worker well-being survey on its psychometric properties, a necessary step to ensure the survey is a validated instrument that can be used to collect accurate and reliable data on worker well-being. At the end of this project, we will produce a survey instrument that has been tested on certain properties and will be in a position to consider dissemination and use.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 79488	11/14/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 18648	04/20/2017
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
National Worker Well-being Survey	none	National Worker Well-being Survey

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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	1,025	0	0	1,025	0	0
Annual Time Burden (Hours)	342	0	0	342	0	0
Annual Cost Burden (Dollars)	7,937	0	0	7,937	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 resubmission of a new ICR that was withdrawn in 2017.

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Annual Cost to Federal Government: $52,815

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

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Common Form ICR:  No

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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: 03/13/2018

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