Coal Workers' Health Surveillance Program (CWHSP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CDC/NIOSH (M) 2.8 Roentgenographic Interpretation	Form	Modified	Available
Form 9 Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	Form and Instruction	New	Available
Form 6 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	Form	New	Repair queued
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)	Form	New	Available
Form 9 Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	Form and Instruction	New	Available
Form 6 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	Form	New	Available
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)	Form	New	Available
Form 9 Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	Form and Instruction	New	Available
Form 6 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	Form	New	Repair queued
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)	Form	New	Repair queued
Form 6 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	Form	New	Available
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)	Form	New	Available
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)	Form	New	Available
Form CDC/NIOSH (M) 2.12 Facility Certification Document	Form and Instruction	Modified	Available
Form CDC/NIOSH (M) 2.11 Facility Certification Document	Form and Instruction	Modified	Available
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan	Form and Instruction	Modified	Available
Form CDC/NIOSH (M) 2.9 Miner Identification Document	Form and Instruction	Modified	Available
Form 4 Facility Certification Document	Form	Modified	Available
Form CDC/NIOSH (M) 2.11 Facility Certification Document	Form and Instruction	Modified	Available
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan	Form and Instruction	Modified	Repair queued
Form CDC/NIOSH (M) 2.9 Miner Identification Document	Form and Instruction	Modified	Available
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan	Form and Instruction	Modified	Available
Form CDC/NIOSH (M) 2.9 Miner Identification Document	Form and Instruction	Modified	Available
Form CDC/NIOSH (M) 2.9 Miner Identification Document	Form and Instruction	Modified	Available
SuppStmt B 04.14.11.docx	Supporting Statement B	Uploaded 2011-04-25	Available
Attmt 13- 4.18.11.docx	Supplementary Document	Uploaded 2011-04-26	Available
Attmt 3- 42 CFR Part 37 4.14.11.doc	Supplementary Document	Uploaded 2011-04-25	Available
SuppStat A_ 04 26 14 (2).doc	Supporting Statement A	Uploaded 2011-04-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6620	Roentgenographic Interpretation	Form	Modified	Roentgenographic Interpretation
197450	Coal Workers' Health Surveillance Program (CWHSP)-X-ray Coal Miners	Form and Instruction	New	Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
197450	Coal Workers' Health Surveillance Program (CWHSP)-X-ray Coal Miners	Form	New	Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
197450	Coal Workers' Health Surveillance Program (CWHSP)-X-ray Coal Miners	Form	New	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
197449	Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test	Form and Instruction	New	Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
197449	Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test	Form	New	Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
197449	Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test	Form	New	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
197448	Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	Form and Instruction	New	Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
197448	Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	Form	New	Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
197448	Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	Form	New	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
197447	Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	Form	New	Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
197447	Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	Form	New	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
197446	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)	Form	New	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
183370	Interpretating Physician Certification Document	Form and Instruction	Modified	Facility Certification Document
183370	Interpretating Physician Certification Document	Form and Instruction	Modified	Facility Certification Document
183370	Interpretating Physician Certification Document	Form and Instruction	Modified	Coal Mine Operator's Plan
183370	Interpretating Physician Certification Document	Form and Instruction	Modified	Miner Identification Document
183369	Facility Certification Document	Form	Modified	Facility Certification Document
183369	Facility Certification Document	Form and Instruction	Modified	Facility Certification Document
183369	Facility Certification Document	Form and Instruction	Modified	Coal Mine Operator's Plan
183369	Facility Certification Document	Form and Instruction	Modified	Miner Identification Document
183368	Coal Mine Operator's Plan	Form and Instruction	Modified	Coal Mine Operator's Plan
183368	Coal Mine Operator's Plan	Form and Instruction	Modified	Miner Identification Document
183367	Miner Identification Document	Form and Instruction	Modified	Miner Identification Document

ICR Details

OMB Control No: 0920-0020	ICR Reference No: 201104-0920-016
Status: Historical Active	Previous ICR Reference No: 200801-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Coal Workers' Health Surveillance Program (CWHSP)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/04/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/26/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2014	36 Months From Approved	06/30/2011
Responses	23,250	0	15,525
Time Burden (Hours)	4,471	0	2,330
Cost Burden (Dollars)	0	0	0

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Abstract: This submission will incorporate the National Coal Workers' X-Ray Surveillance Program 42 CFR 37 (0920-0020) and National Coal Workers' Autopsy Study 42 CFR Part 37.204 (0920-0021) into one complete package which will be called the Coal Workers' Health Surveillance Program (CWHSP).

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Authorizing Statute(s): PL: Pub.L. 95 - 164 111 Name of Law: Federal Mine Safety & Health Act of 1977, Public Law 91-173, as amended by Public Law 95-164
   PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 10369	02/24/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 22902	04/25/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Coal Mine Operator's Plan	CDC/NIOSH (M) 2.9, CDC/NIOSH (M) 2.10	Miner Identification Document ,   Coal Mine Operator's Plan
Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	5, 6	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) ,   Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	5, 6, 9	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) ,   Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist ,   Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)	5	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test	5, 6, 9	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) ,   Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist ,   Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Coal Workers' Health Surveillance Program (CWHSP)-X-ray Coal Miners	5, 6, 9	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) ,   Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist ,   Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Facility Certification Document	CDC/NIOSH (M) 2.9, CDC/NIOSH (M) 2.10, CDC/NIOSH (M) 2.11, 4	Miner Identification Document ,   Coal Mine Operator's Plan ,   Facility Certification Document ,   Facility Certification Document
Interpretating Physician Certification Document	CDC/NIOSH (M) 2.9, CDC/NIOSH (M) 2.10, CDC/NIOSH (M) 2.11, CDC/NIOSH (M) 2.12	Miner Identification Document ,   Coal Mine Operator's Plan ,   Facility Certification Document ,   Facility Certification Document
Miner Identification Document	CDC/NIOSH (M) 2.9	Miner Identification Document
Roentgenographic Interpretation	CDC/NIOSH (M) 2.8	Roentgenographic Interpretation

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ICR Summary of Burden

table that charts list of burden

	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	23,250	15,525	0	0	7,725	0
Annual Time Burden (Hours)	4,471	2,330	0	0	2,141	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We are requesting an increase of 2141 burden hours for this approval period due to the increase in the number of participating miners, and an increase in the number of applications from newly eligible digital x-ray facilities. This increase also reflects the increase related to the combining of the two OMB submissions (0920-0020 and 0920-0021) into one comprehensive CWHSP packet.

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Annual Cost to Federal Government: $1,146,488

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/26/2011

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