Information Collection

Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kin (form 2.6)

IC 197446 under ICR 201302-0920-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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)-Consent Release and History Form- Next of Kin (form 2.6)	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

IC Title:

Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kin (form 2.6)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	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

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	13	13
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.