Information Collection

X-ray Coal Miners (CWHSP)

IC 197450 under ICR 201406-0920-018 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 5 X-ray Coal Miners (CWHSP)	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
6 Coal Workers' Health Surveillance Program (CWHSP)- Invoi Attmt 10- Pathologist Invoice Sample.pdf	Form
9 Coal Workers' Health Surveillance Program (CWHSP)- Repor Attmt 11- NCWAS checklist 4.18.11 (2).doc	Form and Instruction

IC Title:

X-ray Coal Miners (CWHSP)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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
Form	6	Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	Attmt 10- Pathologist Invoice Sample.pdf	No	No	Paper Only
Form and Instruction	9	Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	Attmt 11- NCWAS checklist 4.18.11 (2).doc	No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-20-0153 Mortality Studies in Coal Mining

FR Citation: 51 FR 42478

Number of Respondents: 10,383

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,383	5,383	5,000
Annual IC Time Burden (Hours)	2,596	1,346	1,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.