National Coal Workers' Health Surveillance Program (CWHSP)

Forms and Documents

Document Name	Status
Form 2.8 Chest Radiograph Classification (CDC/NIOSH Form 2.8) Form	Unchanged
Form 2.18 Coal Contractor Plan CDC/NIOSH 2.18 Form	Unchanged
Form 2.15 Spirometry Results Notification CDC/NIOSH 2.15 Form	Modified
Form 2.14 Spirometry Facility Supervisor - Certification Document 2.14 Form	Unchanged
Form 2.13 Spirometry Facility Employee - Respiratory Assessment 2.13 Form	Unchanged
Form 2.6 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form	Unchanged
Form 2.12 Physician Application for Certification (CDC/NIOSH 2.12) Form	Unchanged
Form 2.11 Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form	Unchanged
Form 2.10 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form	Unchanged
Form 2.9 Miner Identification Document (CDC/NIOSH 2.9) Form	Modified
Request for Nonsubstantive Change to 2 9 and 2 15.docx Justification for No Material/Nonsubstantive Change	2016-04-12
Attachment 25.docx Supplementary Document	2015-03-18
Attachment 24.docx Supplementary Document	2015-03-18
Attachment 23- 60day.pdf Supplementary Document	2015-03-18
Attachment 2.docx Supplementary Document	2015-03-18
SupSta B.docx Supporting Statement B	2015-03-18
SupSta A_ 03 11 2015.docx Supporting Statement A	2015-03-18
Attachment 1- revised.docx Supplementary Document	2014-07-30
Att 15_42CFR Part 37.docx Supplementary Document	2014-03-07
Att 1_Medical Exam excerpt.docx Supplementary Document	2014-03-07

IC Document Collections

IC ID	Document Title	Status
6620	Chest Radiograph Classification (CDC/NIOSH Form 2.8) Form	Unchanged
212093	Coal Contractor Plan CDC/NIOSH 2.18 Form	Unchanged
212090	Spirometry Results Notification CDC/NIOSH 2.15 Form	Modified
212089	Spirometry Facility Supervisor - Certification Document 2.14 Form	Unchanged
212086	Spirometry Facility Employee - Respiratory Assessment 2.13 Form	Unchanged
197450	Coal Miner Radiograph (CWHSP) Instruction	Unchanged
197449	Spirometry Test for Coal Miners Instruction	Unchanged
197448	Report - Pathologist Instruction	Unchanged
197447	Invoice-Pathologist Instruction	Unchanged
197446	Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form	Unchanged
183370	Physician Application for Certification (CDC/NIOSH 2.12) Form	Unchanged
183369	Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form	Unchanged
183368	Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form	Unchanged
183367	Miner Identification Document (CDC/NIOSH 2.9) Form	Modified

ICR Details

OMB Control No: 0920-0020	ICR Reference No: 201604-0920-005
Status: Historical Active	Previous ICR Reference No: 201503-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No: 16ABJ
Title: National Coal Workers' Health Surveillance Program (CWHSP)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/13/2016
	Date Received in OIRA: 04/13/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2018	06/30/2018	06/30/2018
Responses	104,158	0	104,158
Time Burden (Hours)	20,276	0	20,276
Cost Burden (Dollars)	0	0	0

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Abstract: The Coal Workers' Health Surveillance Program (CWHSP) is a congressionally-mandated medical examination program for monitoring the health of underground coal miners, established under the Federal Coal Mine Health and Safety Act of 1969. Through delegation of authority, the Act directs NIOSH to study the causes and consequences of coal-related respiratory disease, and in cooperation with the Mine Safety and Health Administration, to carry out a program for early detection and prevention of coal workers' pneumoconiosis and to provide the opportunity for an autopsy after the death of a coal miner.

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Authorizing Statute(s): PL: Pub.L. 91 - 173 203 Name of Law: Federal Coal Mine Health and Safety Act
   PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health Act
   US Code: 42 USC 37 Name of Law: Specifications for Medical Exam of Coal Miners
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 74094	12/15/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 14143	03/18/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 14

IC Title	Form No.	Form Name
Chest Radiograph Classification (CDC/NIOSH Form 2.8)	2.8	Chest Radiograph Classification
Miner Identification Document (CDC/NIOSH 2.9)	2.9, 2.9	Miner Identification Document ,   Miner Identificaiton Document
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10)	2.10	Coal Mine Operator's Plan
Radiographic Facility Certification (CDC/NIOSH (M) 2.11)	2.11	Radiographic Facility Certification
Physician Application for Certification (CDC/NIOSH 2.12)	2.12	Physician Application for Certification
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)	2.6	Consent, Release and History Form for Autopsy
Invoice-Pathologist
Report - Pathologist
Spirometry Test for Coal Miners
Coal Miner Radiograph (CWHSP)
Spirometry Facility Employee - Respiratory Assessment 2.13	2.13	Respiratory Assessment
Spirometry Results Notification CDC/NIOSH 2.15	2.15, 2.15	Spirometry Results Notification ,   Spirometry Results Notification Form
Spirometry Facility Supervisor - Certification Document 2.14	2.14	Spirometry Facility Certification
Coal Contractor Plan CDC/NIOSH 2.18	2.18	Coal Contractor Plan

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ICR Summary 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	104,158	104,158	0	0	0	0
Annual Time Burden (Hours)	20,276	20,276	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,262,097

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/13/2016

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