Self-Reported Low Back Pain Questionnaire - Original Data Collection

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

Documents and Forms

Document Name Document Type
Self-Reported Low Back Pain Questionnaire - Original Data Collection Form and Instruction
Self-Reported Low Back Pain Questionnaire Attachment H-1 Self Report Low Back Pain.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Self-Reported Low Back Pain Questionnaire - Original Data Collection	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Self-Reported Low Back Pain Questionnaire	Attachment H-1 Self Report Low Back Pain.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 87	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	305	-4,015	4,320
Annual IC Time Burden (Hours)	25	-335	360
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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