Form CDC/NIOSH (M) 2.12 CDC/NIOSH (M) 2.12 Physical Application for Certification

National Coal Workers' X-ray Surveillance Program (CWXSP) - Federal Mine Safety and Health Act 1977 (42CFR37)

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0020 can be found here:

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Attachment 7

Physician Application for Certification – CDC/NIOSH (M) 2.12

2 sided form (printed front and back)

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	CDC User
File Modified	0000-00-00
File Created	2021-01-27