Information Collection

Physician Application for Certification (CDC/NIOSH 2.12)

IC 183370 under ICR 201503-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

View Information Collection (IC)

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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

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.