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 (CDC/NIOSH Form 2.8) Form Modified Available
Form 2.18 Coal Contractor Plan 2.18 Form New Available
Form 2.17 Spirometry Technician - Results Form 2.17 Form New Available
Form 2.16 Spirometry Facility Employee - Notification form 2.16 Form New Repair queued
Form 2.15 Spirometry Technician - Pre-test Checklist 2.15 Form New Available
Form 2.14 Spirometry Facility Supervisor - Certification Document 2.14 Form New Available
Form 2.13 Spirometry Facility Employee - Respiratory Assessment 2.13 Form New Repair queued
Form 5 X-ray Coal Miners (CWHSP) Form Modified Available
Form CDC/NIOSH 2.6 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form Modified Available
Form CDC/NIOSH (M) 2.12 Physician Application for Certification (CDC/NIOSH (M) 2.12) Form Modified Available
Form CDC/NOISH (M) 2.11 Facility Certification Document (CDC/NIOSH (M) 2.11) Form Modified Available
Form 2.10 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form and Instruction Modified Available
Form CDC/NOISH (M) 2.9 Miner Identification Document (CDC/NIOSH 2.9) 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

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 Chest Radiograph Classification
Miner Identification Document (CDC/NIOSH 2.9) CDC/NOISH (M) 2.9 Miner Identification Document
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) 2.10 Coal Operator's Plan
Facility Certification Document (CDC/NIOSH (M) 2.11) CDC/NOISH (M) 2.11 Facility Certification Document
Physician Application for Certification (CDC/NIOSH (M) 2.12) CDC/NIOSH (M) 2.12 Physical Application for Certification
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) CDC/NIOSH 2.6 Consent, Release and History Form
Invoice-Pathologist (CWHSP)
Report Pathologist (CWHSP)
Spirometry Test for Coal Miners
X-ray Coal Miners (CWHSP) 5, 6, 9 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) ,   Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist ,   Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Spirometry Facility Employee - Respiratory Assessment 2.13 2.13 Respiratory Assessment
Spirometry Technician - Pre-test Checklist 2.15 2.15 Spirometry Pre-test Checklist
Spirometry Facility Employee - Notification form 2.16 2.16 Spriometry Notification
Spirometry Facility Supervisor - Certification Document 2.14 2.14 Facility Certification
Spirometry Technician - Results Form 2.17 2.17 Spirometry Results
Coal Contractor Plan 2.18 2.18 Coal Contractor Plan

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