OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Musculoskeletal Disorder (MSD) Intervention Effectiveness in an Insurer-Supported Engineering Control Program

ICR 201409-0920-008 · OMB 0920-0907 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Early Exit Interview - Additional Data Collection Form and Instruction New Available
Self-Reported General Work Environment and Health Questionnaire - Additional Data Collection Form and Instruction New Repair queued
Self-Reported Specific Job Tasks and Safety Incidents Questionnaire - Additional Data Collection Form and Instruction New Available
Self-Reported Shoulder/Arm (Upper Extremity) Pain Questionnaire - Additional Data Collection Form and Instruction New Available
Self-Reported Low Back Questionnaire - Additional Data Collection Form and Instruction New Available
Early Exit Interview - Original Data Collection Form and Instruction Modified Available
Form 7 Low Back Functional Assessment Form and Instruction Removed Available
Self-Reported General Work Environment and Health Questionnaire - Original Data Collection Form and Instruction Modified Available
Self-Reported Specific Job Tasks and Safety Incidents Questionnaire - Original Data Collection Form and Instruction Modified Available
Self-Reported Shoulder/Arm (Upper Extremity) Pain Questionnaire - Original Data Collection Form and Instruction Modified Available
Self-Reported Low Back Pain Questionnaire - Original Data Collection Form and Instruction Modified Available
Form 2 Informed Consent- Low Back Functional Assessment Form and Instruction Removed Repair queued
Informed Consent (Questionnaire Data Collection) Form and Instruction Modified Repair queued
Attachment L-5 Study Limitations.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment L-3 MSD Study Outcomes.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment L-1 Interventions.docx Supplementary Document Uploaded 2014-09-10 Repair queued
Attachment K IRB Approval.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment J-4 Indiv Recruitment Flyer.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment J-3 OBWC Safety Grant 2.docx Supplementary Document Uploaded 2014-09-10 Repair queued
Attachment J-2 OBWC Safety Grant 1.docx Supplementary Document Uploaded 2014-09-10 Repair queued
Attachment J-1 Recruitment Flyer.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment G-3 Photograph Consent.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment G-1 Informed Consent.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment F Information Security.docx Supplementary Document Uploaded 2014-09-10 Repair queued
Attachment E-3 US_Ohio Codes.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment E-2 OBWC Letter of Support.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment E-1 OBWC_NIOSH Agreement.docx Supplementary Document Uploaded 2014-09-10 Repair queued
Attachment D-2 MSD Intervention Studies.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment D-1 Relation to CDC Research.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment C NIOSH Strategic Goals.docx Supplementary Document Uploaded 2014-09-10 Available
Attachment B 60d FRN.pdf Supplementary Document Uploaded 2014-09-10 Available
Attachment A Authorizing Legislation.docx Supplementary Document Uploaded 2014-09-10 Repair queued
Section B MSD Intervention 2_10_15.docx Supporting Statement B Uploaded 2015-02-13 Available
Section A MSD Intervention 2_09_15.docx Supporting Statement A Uploaded 2015-02-13 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
215010 Early Exit Interview - Additional Data Collection Form and Instruction New
215007 Self-Reported General Work Environment and Health Questionnaire - Additional Data Collection Form and Instruction New
215006 Self-Reported Specific Job Tasks and Safety Incidents Questionnaire - Additional Data Collection Form and Instruction New
215005 Self-Reported Shoulder/Arm (Upper Extremity) Pain Questionnaire - Additional Data Collection Form and Instruction New
215004 Self-Reported Low Back Questionnaire - Additional Data Collection Form and Instruction New
198869 Early Exit Interview - Original Data Collection Form and Instruction Modified
198868 Low Back Functional Assessment Form and Instruction Removed
198867 Self-Reported General Work Environment and Health Questionnaire - Original Data Collection Form and Instruction Modified
198866 Self-Reported Specific Job Tasks and Safety Incidents Questionnaire - Original Data Collection Form and Instruction Modified
198865 Self-Reported Shoulder/Arm (Upper Extremity) Pain Questionnaire - Original Data Collection Form and Instruction Modified
198864 Self-Reported Low Back Pain Questionnaire - Original Data Collection Form and Instruction Modified
198863 Informed Consent- Low Back Functional Assessment Form and Instruction Removed
198862 Informed Consent (Questionnaire Data Collection) Form and Instruction Modified
ICR Details
0920-0907 201409-0920-008
Historical Active 201108-0920-004
HHS/CDC
Musculoskeletal Disorder (MSD) Intervention Effectiveness in an Insurer-Supported Engineering Control Program
Revision of a currently approved collection   No
Regular
Approved with change 03/02/2015
Retrieve Notice of Action (NOA) 09/17/2014
  Inventory as of this Action Requested Previously Approved
03/31/2017 24 Months From Approved 03/31/2015
4,154 0 15,701
382 0 1,500
0 0 0
NIOSH proposes a revision to continue conducting a study in partnership with the Ohio Bureau of Workers Compensation (OBWC) to assess the effectiveness of occupational safety and health interventions for musculoskeletal disorders. This revision will allow a previously approved data collection to be completed on currently participating employers/employees (using a previously approved protocol) and allow new employers/employees to be enrolled (using a modified protocol). The original protocol uses a randomized control design where 33 employers were matched based on the similarity of employee tasks, prior loss history, and the affected number of employees prior to the intervention being into place. The main outcomes are self-reported back and upper extremity pain among employees performing material handling operations. To complete the data collection on the 103 currently employees using the original protocol, 292 remaining surveys need to be completed, requiring 21 additional months. NIOSH is also requesting approval of a modified protocol moving forward to allow new employers and up to 200 employees to be enrolled for an additional 2 year study. The new study design still involves collecting symptoms at baseline before the intervention and after the intervention is put into place. However, the protocol is modified from the original data collection in that 1) all employers will now receive the intervention immediately, rather than half being randomly selected to receive the intervention six months later; 2) a low back functional assessment is no longer being conducted; and 3) the study population now includes employees performing material handling and patient handling tasks in all industries. These changes were necessary because the expansion of the OBWC intervention program inadvertently removed some incentives to participate in the original study. OBWC asked NIOSH to continue to measure the effectiveness of the program in terms of employee symptoms and other detailed measures because the new expansion gives the opportunity to increase the generalizability of study findings to a greater variety of industries, including health care, and tasks, including patient handling.
PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health Act of 1970
  
None
Not associated with rulemaking
  79 FR 32299 06/04/2014
79 FR 54982 09/15/2014
No
11
IC Title Form No. Form Name
Self-Reported Specific Job Tasks and Safety Incidents Questionnaire - Additional Data Collection None Self-Reported Specific Job Tasks and Safety Incidents Questionnaire
Self-Reported General Work Environment and Health Questionnaire - Additional Data Collection None Self Reported General Work Environment and Heath Questionnaire
Self-Reported Low Back Questionnaire - Additional Data Collection None Self-Reported Low Back Pain Questionnaire
Self-Reported Shoulder/Arm (Upper Extremity) Pain Questionnaire - Additional Data Collection None Self-Reported Shoulder/Arm Pain Questionnaire
Early Exit Interview - Additional Data Collection None Early Exit Interview
Low Back Functional Assessment 7 Low Back Functional Assessment
Informed Consent- Low Back Functional Assessment 2 Informed Consent- Low Back Functional Assessment
Informed Consent (Questionnaire Data Collection) None Informed Consent
Self-Reported Low Back Pain Questionnaire - Original Data Collection None Self-Reported Low Back Pain Questionnaire
Self-Reported Shoulder/Arm (Upper Extremity) Pain Questionnaire - Original Data Collection None Self-Reported Shoulder/Arm Pain Questionnaire
Self-Reported Specific Job Tasks and Safety Incidents Questionnaire - Original Data Collection None Self-Reported Specific Job Tasks and Safety Incidents Questionnaire
Self-Reported General Work Environment and Health Questionnaire - Original Data Collection None Self-Reported General Workk Environment and Health Questionnaire
Early Exit Interview - Original Data Collection None Early Exit Interview
  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 4,154 15,701 0 -11,547 0 0
Annual Time Burden (Hours) 382 1,500 0 -1,118 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
NIOSH has removed a Low Back Functional Assessment Questionnaire and Informed Consent Form resulting in a decrease in Burden Hours.
$25,050
Yes Part B of Supporting Statement
Yes
No
No
No
Uncollected
Jeffrey Zirger 404 639-7118 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/17/2014