Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....

Claim adjudication process for alleged presence of pneumoconiosis

Documents and Forms

Document Name Document Type
Form CM-988 Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form
CM-933 Roentgenographic Interpretation CM-933 Rev June 2008.pdf www.dol.gov/esa/regs/compliance/owcp/cm-933.pdf Form
CM-933B Roentgenographic Quality Rereading CM-933 Rev June 2008.pdf www.dol.gov/esa/regs/compliance/owcp/cm-933b.pdf Form
CM-988 Medical History and Examination for Coal Mine Workers' P cm-988.pdf www.dol.gov/esa/regs/compliance/owcp/cm-988.pdf Form
CM-2907 Report of Ventilatory Study cm-2907.pdf www.dol.gov/esa/regs/compliance/owcp/cm-2907.pdf Form
CM-1159 Report of Arterial Blood Gas Study CM-1159 June 2008.doc Form

Information Collection (IC) Details

IC Title:	Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 718.102-105

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-988	Medical History and Examination for Coal Mine Workers' Pneumoconiosis	cm-988.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-988.pdf	Yes	No	Fillable Printable
Form	CM-2907	Report of Ventilatory Study	cm-2907.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-2907.pdf	Yes	No	Fillable Printable
Form	CM-933	Roentgenographic Interpretation	CM-933 Rev June 2008.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-933.pdf	Yes	No	Fillable Printable
Form	CM-1159	Report of Arterial Blood Gas Study	CM-1159 June 2008.doc		Yes	No	Fillable Printable
Form	CM-933B	Roentgenographic Quality Rereading	CM-933 Rev June 2008.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-933b.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ESA-6, DOL/ESA-30	FR Citation: 67 FR 16869

Number of Respondents: 17,500	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	17,500	17,500
Annual IC Time Burden (Hours)	4,259	4,259
Annual IC Cost Burden (Dollars)	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.