Information Collection

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

IC 197446 under ICR 201306-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.