National Coal Workers' Health Surveillance Program (CWHSP)

Forms and Documents

Document Name	Status
Form 0920-0020 Chest Radiograph Classification (CDC/NIOSH Form 2.8) Form	Modified
Form 2.18 Coal Contractor Plan CDC/NIOSH 2.18 Form	Unchanged
Form 2.15 Spirometry Results Notification CDC/NIOSH 2.15 Form	Unchanged
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 0920-0020 Physician Application for Certification (CDC/NIOSH 2.12) Form	Modified
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 0920-0020 Miner Identification Document (CDC/NIOSH 2.9) Form	Modified
Request for Nonsubstantive Change 2019.docx Justification for No Material/Nonsubstantive Change	2019-03-26
Attachment 27 Public Comments .docx Supplementary Document	2018-06-25
Attachment 25 OCISO PII.docx Supplementary Document	2018-06-25
Attachment 24 OCISO SSN.docx Supplementary Document	2018-06-25
Attachment 18 Sample Letter Spiro Results.docx Supplementary Document	2018-06-25
Attachment 14 Sample Letter B Reader Due to Recertify.docx Supplementary Document	2018-06-25
Attachment 13 Sample Letters B Reader Exam Results.docx Supplementary Document	2018-06-25
Attachment 10 Sample Letter Results.docx Supplementary Document	2018-06-25
Attachment 9 Sample Letter Participation.docx Supplementary Document	2018-06-25
Attachment 7 Sample Letter Rad Fac Approval.docx Supplementary Document	2018-06-25
Attachment 5 Sample Letters.docx Supplementary Document	2018-06-25
Attachment 2 42 CFR Part 37.docx Supplementary Document	2018-06-20
Attachment 23 Stakeholder Information.docx Supplementary Document	2018-06-20
Attachment 26 IRB Determination.docx Supplementary Document	2018-06-20
60 day FRN.pdf Supplementary Document	2018-06-19
Attachment 2.docx Supplementary Document	2015-03-18
SupSta B_0920-0020 CWHSP 03 05 2018.docx Supporting Statement B	2018-06-19
SupSta A_0920-0020_ICRO edits formatting.docx Supporting Statement A	2018-06-28
Attachment 1- revised.docx Supplementary Document	2014-07-30
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	Modified
212093	Coal Contractor Plan CDC/NIOSH 2.18 Form	Unchanged
212090	Spirometry Results Notification CDC/NIOSH 2.15 Form	Unchanged
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	Modified
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: 201903-0920-009
Status: Active	Previous ICR Reference No: 201806-0920-008
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0020
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: 04/23/2019
	Date Received in OIRA: 04/17/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2021	09/30/2021	09/30/2021
Responses	104,126	0	104,146
Time Burden (Hours)	20,274	0	20,278
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. An extension is being requested with only a few minor changes (costs). This Non-Substantive Change Request is submitted to make minor changes to the following forms/procedures: Chest Radiograph Classification Form Miner Identification Document Physician Application for Certification Recertification period for B Readers Changes result in an overall decrease in four Burden Hours.

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Authorizing Statute(s): 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
   PL: Pub.L. 91 - 173 203 Name of Law: Federal Coal Mine Health and Safety Act
  

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:
	83 FR 15840	04/12/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 29556	06/25/2018
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Spirometry Results Notification CDC/NIOSH 2.15	2.15	Spirometry Results Notification form edit
Spirometry Facility Supervisor - Certification Document 2.14	2.14	Spirometry Facility Certification
Coal Contractor Plan CDC/NIOSH 2.18	2.18	Coal Contractor Plan
Chest Radiograph Classification (CDC/NIOSH Form 2.8)	2.8, 0920-0020	Chest Radiograph Classification Form M 2.8 25MAR2019 ,   Chest Radiograph Classification
Miner Identification Document (CDC/NIOSH 2.9)	0920-0020, 2.9, 2.9	Miner Identification Document Form M 2.9 25MAR2019 ,   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, 0920-0020	Physician Application for Certification Form 2.12 25MAR2019 ,   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

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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	104,126	104,146	0	-20	0	0
Annual Time Burden (Hours)	20,274	20,278	0	-4	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Non-Substantive Change Request is submitted to make minor changes to the following forms: Chest Radiograph Classification Form, Miner Identification Document, Physician Application for Certification Change in the recertification period for B Readers results in an overall decrease in four Burden Hours.

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Annual Cost to Federal Government: $2,499,239

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 04/17/2019

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