Physician Application for Certification (CDC/NIOSH 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⚠️ Notice: This information collection may be referencing outdated material.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 2.12 Physician Application for Certification (CDC/NIOSH 2.12) Form
2.12 Physician Application for Certification Attachment 12.docx Form

Information Collection (IC) Details

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

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2.12	Physician Application for Certification	Attachment 12.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0149-Morbidity 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: 51 FR 42476

Number of Respondents: 100	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	100	50	50
Annual IC Time Burden (Hours)	17	9	8
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.