Information Collection

Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test

IC 197449 under ICR 201104-0920-016 · OMB 0920-0020.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test	Form
5 Coal Workers' Health Surveillance Program (CWHSP)-Consen Attmt 9- CDC NIOSH 2.6 NCWAS Consent Release History Form 4.18.11.doc	Form
6 Coal Workers' Health Surveillance Program (CWHSP)- Invoi Attmt 10- Pathologist Invoice Sample.pdf	Form
9 Coal Workers' Health Surveillance Program (CWHSP)- Repor Attmt 11- NCWAS checklist 4.18.11 (2).doc	Form and Instruction

IC Title:

Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	5	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)	Attmt 9- CDC NIOSH 2.6 NCWAS Consent Release History Form 4.18.11.doc	No	No	Paper Only
Form	6	Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	Attmt 10- Pathologist Invoice Sample.pdf	No	No	Paper Only
Form and Instruction	9	Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	Attmt 11- NCWAS checklist 4.18.11 (2).doc	No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	833	833
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.