Information Collection

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

IC 13765 under ICR 201003-1240-023 · OMB 1240-0023.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0023 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-933B Roentgenographic Quality Rereading Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form
Form CM-933 Roentgenographic Interpretation Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form
Form CM-988 Medical History and Examination for Coal Mine Workers' Pneumoconiosis Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form
Form CM-2907 Report of Ventilatory Study Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form
Form CM-1159 Report of Arterial Blood Gas Study 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

View Information Collection (IC)

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:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-933	http://www.dol.gov/esa/regs/compliance/owcp/cm-933.pdf	Yes	No	Fillable Printable
Form	CM-933B	http://www.dol.gov/esa/regs/compliance/owcp/cm-933b.pdf	Yes	No	Fillable Printable
Form	CM-988	http://www.dol.gov/esa/regs/compliance/owcp/cm-988.pdf	Yes	No	Fillable Printable
Form	CM-2907	http://www.dol.gov/esa/regs/compliance/owcp/cm-2907.pdf	Yes	No	Fillable Printable
Form	CM-1159		Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].