Information Collection Request

National Coal Workers' Health Surveillance Program (CWHSP)

ICR 201406-0920-018 · OMB 0920-0020 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CDC/NOISH (M) 2.8 Chest Radiograph Classification Form Modified Available
Form 2.18 Coal Contractor Plan Form New Available
Form 2.17 Spirometry Results Form New Available
Form 2.16 Spriometry Notification Form New Repair queued
Form 2.15 Spirometry Pre-test Checklist Form New Available
Form 2.14 Facility Certification Form New Available
Form 2.13 Respiratory Assessment Form New Repair queued
Form 9 Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist Form and Instruction Modified Available
Form 6 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist Form Modified Available
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) Form Modified Available
Form CDC/NIOSH 2.6 Consent, Release and History Form Form Modified Available
Form CDC/NIOSH (M) 2.12 Physical Application for Certification Form Modified Available
Form CDC/NOISH (M) 2.11 Facility Certification Document Form Modified Available
Form 2.10 Coal Operator's Plan Form and Instruction Modified Available
Form CDC/NOISH (M) 2.9 Miner Identification Document Form and Instruction Modified Available
Attachment 1- revised.docx Supplementary Document Uploaded 2014-07-30 Available
SupSta A_0920-0020 7 29 14 NIOSH-2 edits.docx Supporting Statement A Uploaded 2014-07-30 Available
SupSta B_0920-0020.docx Supporting Statement B Uploaded 2014-06-25 Repair queued
Att 15_42CFR Part 37.docx Supplementary Document Uploaded 2014-03-07 Available
Att 14_Contact Information.docx Supplementary Document Uploaded 2014-03-07 Repair queued
Att 13_IRB.docx Supplementary Document Uploaded 2014-03-07 Available
Att 2_60d published FRN.pdf Supplementary Document Uploaded 2014-03-07 Available
Att 1_Medical Exam excerpt.docx Supplementary Document Uploaded 2014-03-07 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
6620 Chest Radiograph Classification (CDC/NIOSH Form 2.8) Form ModifiedChest Radiograph Classification
212093 Coal Contractor Plan 2.18 Form NewCoal Contractor Plan
212092 Spirometry Technician - Results Form 2.17 Form NewSpirometry Results
212091 Spirometry Facility Employee - Notification form 2.16 Form NewSpriometry Notification
212090 Spirometry Technician - Pre-test Checklist 2.15 Form NewSpirometry Pre-test Checklist
212089 Spirometry Facility Supervisor - Certification Document 2.14 Form NewFacility Certification
212086 Spirometry Facility Employee - Respiratory Assessment 2.13 Form NewRespiratory Assessment
197450 X-ray Coal Miners (CWHSP) Form and Instruction ModifiedCoal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
197450 X-ray Coal Miners (CWHSP) Form ModifiedCoal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
197450 X-ray Coal Miners (CWHSP) Form ModifiedCoal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
197449 Spirometry Test for Coal Miners Instruction Modified
197448 Report Pathologist (CWHSP) Instruction Modified
197447 Invoice-Pathologist (CWHSP) Instruction Modified
197446 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form ModifiedConsent, Release and History Form
183370 Physician Application for Certification (CDC/NIOSH (M) 2.12) Form ModifiedPhysical Application for Certification
183369 Facility Certification Document (CDC/NIOSH (M) 2.11) Form ModifiedFacility Certification Document
183368 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form and Instruction ModifiedCoal Operator's Plan
183367 Miner Identification Document (CDC/NIOSH 2.9) Form and Instruction ModifiedMiner Identification Document

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
02/28/2015 6 Months From Approved 05/31/2017
94,744 0 22,915
16,359 0 4,418
0 0 0





Reginfo record details
16
table that charts list of burden
IC Title Form No. Form Name
Chest Radiograph Classification (CDC/NIOSH Form 2.8) CDC/NOISH (M) 2.8
Coal Contractor Plan 2.18 2.18
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) 2.10
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) CDC/NIOSH 2.6
Facility Certification Document (CDC/NIOSH (M) 2.11) CDC/NOISH (M) 2.11
Invoice-Pathologist (CWHSP)
Miner Identification Document (CDC/NIOSH 2.9) CDC/NOISH (M) 2.9
Physician Application for Certification (CDC/NIOSH (M) 2.12) CDC/NIOSH (M) 2.12
Report Pathologist (CWHSP)
Spirometry Facility Employee - Notification form 2.16 2.16
Spirometry Facility Employee - Respiratory Assessment 2.13 2.13
Spirometry Facility Supervisor - Certification Document 2.14 2.14
Spirometry Technician - Pre-test Checklist 2.15 2.15
Spirometry Technician - Results Form 2.17 2.17
Spirometry Test for Coal Miners
X-ray Coal Miners (CWHSP) 5, 6, 9 ,   ,  

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 94,744 22,915 0 71,829 0 0
Annual Time Burden (Hours) 16,359 4,418 0 11,941 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No