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

National Coal Workers' Health Surveillance Program (CWHSP)

⚠️ Notice: This information collection may be referencing outdated material.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 CDC/NIOSH (M) 2.12 Physician Application for Certification (CDC/NIOSH (M) 2.12) Form
CDC/NIOSH (M) 2.12 Physical Application for Certification Att 7_Form 2.12_Physician Application for Certification.docx Form

Information Collection (IC) Details

IC Title:	Physician Application for Certification (CDC/NIOSH (M) 2.12)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC/NIOSH (M) 2.12	Physical Application for Certification	Att 7_Form 2.12_Physician Application for Certification.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 0920-0149-Mortality Studies in Coal Mining, Metal and Non-Metal Mining and General Industry and 0920-0153- Mortality Studies in coal Mining, Metal and Non-Metal Mining and General Industry.	FR Citation: 72 FR 42414

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	50	-50	100
Annual IC Time Burden (Hours)	8	-9	17
Annual IC Cost Burden (Dollars)	0	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.