Assessment of Occupational Injury among Fire Fighters Using a Follow-back Survey

Forms and Documents

Document Name	Status
Form 0920-18LQ Fire Fighters Follow-back Survey Form and Instruction	New
Responses to comments on OMB package_FF Survey.docx Supplementary Document	2018-10-05
PIA_National Electronic Injury Surveillance System (NEISS).pdf Supplementary Document	2018-10-05
Attachment D_Pre_Interview_Consent_Letter_OMB_Clean.docx Supplementary Document	2018-10-05
Firefighter_PIA.PDF Supplementary Document	2018-07-03
Attachment G_60_Day FRN_Comments.docx Supplementary Document	2018-06-13
Attachment F 17-DSR-05XP Initial Approval Memo Lifting Site Restriction 2017.pdf Supplementary Document	2018-06-13
Attachment E Survey Protocol.docx Supplementary Document	2018-06-13
Attachment D_Pre_Interview_Consent_Letter.docx Supplementary Document	2018-06-13
Attachment A_OSH Act.doc Supplementary Document	2018-06-13
Attachment B 60day FRN.pdf Supplementary Document	2018-06-13
FF_ICR_Section_B May112018_OMB_Clean.doc Supporting Statement B	2018-10-05
FF_ICR_Section_A Sept 28_clean.doc Supporting Statement A	2018-10-05

IC Document Collections

IC ID	Document Title	Status
231809	Fire Fighters Follow-back Survey Form and Instruction	New

ICR Details

OMB Control No: 0920-1244	ICR Reference No: 201806-0920-005
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-18LQ
Title: Assessment of Occupational Injury among Fire Fighters Using a Follow-back Survey
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 with change	Conclusion Date: 10/10/2018
	Date Received in OIRA: 07/05/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved
Responses	240	0	0
Time Burden (Hours)	120	0	0
Cost Burden (Dollars)	2,915	0	0

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Abstract: The purpose of this project is to describe nonfatal occupational injuries and exposures of fire fighters treated in a nationally stratified sample of emergency departments. Data will be collected via telephone interviews. Results will offer insight into characteristics of fire fighters' injuries and exposures in an effort to reduce the number of injuries and exposures in this important workforce.

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Authorizing Statute(s): PL: Pub.L. 91 - 596 20 Name of Law: OSH 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:
	83 FR 6185	02/13/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 26690	06/08/2018
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
Fire Fighters Follow-back Survey	0920-18LQ	Fire Fighter Follow-back Survey revised

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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	240	0	0	240	0	0
Annual Time Burden (Hours)	120	0	0	120	0	0
Annual Cost Burden (Dollars)	2,915	0	0	2,915	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 ICR.

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Annual Cost to Federal Government: $91,471

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: 07/05/2018

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