Report - Pathologist

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⚠️ Notice: This information collection may be referencing outdated material.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
Attachment 28.docx Instruction
Attachment 21.docx Sample Autopsy Report IC Document
Attachment 22.docx Autopsy Checklist IC Document

Information Collection (IC) Details

IC Title:	Report - Pathologist	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attachment 28.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0149 Mortality in Coal Miners	FR Citation: 51 FR 42746

Number of Respondents: 1	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Sample Autopsy Report	Attachment 21.docx	03/19/2015
Autopsy Checklist	Attachment 22.docx	03/19/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.