View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	[NIOSH] Data collection for evidence-based revisions to the Fire Fighter Fatality Investigation and Prevention Program's Medical Line of Duty Death reports	Agency IC Tracking Number:	0920-0953-24AO

IC Status: New

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
Other-WORD			APPENDIX A_FFFIPP Medical report screening questions.docx		No		Paper Only
Other-WORD			APPENDIX B_FFFIPP Medical report verbal consent.docx		No		Paper Only
Other-WORD			APPENDIX C_FFFIPP Med Report Interview Guide No Prev Investigation.docx		No		Paper Only
Other-WORD			APPENDIX D_FFFIPP Med Report Assmt Interview Guide Prev Investigation.docx		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	30	0	30	0	0	0
Annual IC Time Burden (Hours)	76	0	76	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”	Fast_Track_GenIC_Request - FFFIPP LODD reports_10.25.23.docx	10/30/2023

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