Facility Certification Document

Coal Workers' Health Surveillance Program (CWHSP)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0020 can be found here:

Documents and Forms

Document Name Document Type
Form CDC/NIOSH (M) 2.9 Facility Certification Document Form and Instruction
CDC/NIOSH (M) 2.9 Miner Identification Document Form 2.9.pdf Form and Instruction
CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan Form 210.pdf Form and Instruction
CDC/NIOSH (M) 2.11 Facility Certification Document Form 211.pdf Form and Instruction
4 Facility Certification Document Attmt 7- CWHSP-Facility-2.11v2010.pdf Form

Information Collection (IC) Details

IC Title:	Facility Certification Document	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CDC/NIOSH (M) 2.9	Miner Identification Document	Form 2.9.pdf	No	No	Paper Only
Form and Instruction	CDC/NIOSH (M) 2.10	Coal Mine Operator's Plan	Form 210.pdf	No	No	Paper Only
Form and Instruction	CDC/NIOSH (M) 2.11	Facility Certification Document	Form 211.pdf	No	No	Paper Only
Form	4	Facility Certification Document	Attmt 7- CWHSP-Facility-2.11v2010.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 0920-0149-Mortality Studies in Coal Mining, Metal and Non-Metal Mining and General Industry and 0920-0153- Mortality Studies in coal Mining, Metal and Non-Metal Mining and General Industry.	FR Citation: 72 FR 42414

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	100	75	25
Annual IC Time Burden (Hours)	50	37	13
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.