Information Collection

Radiation Sampling and Exposure Records

IC 14336 under ICR 202002-1219-005 · OMB 1219-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0003 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4000-9 Radiation Sampling and Exposure Records	Form and Instruction
4000-9 Record of Individual Exposure to Radon Daughters MSHA Form 4000-9 (Record of Individual Exposure to Radon Daughters).pdf www.msha.gov/sites/default/files/Support_Resources/Forms/4000-9.pdf	Form and Instruction

IC Title:

Radiation Sampling and Exposure Records

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 57.5040 30 CFR 57.5037

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 and Instruction	4000-9	Record of Individual Exposure to Radon Daughters	MSHA Form 4000-9 (Record of Individual Exposure to Radon Daughters).pdf	https://www.msha.gov/sites/default/files/Support_Resources/Forms/4000-9.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: DOL-MSHA 1, Mine Safety and Health Administration Standardized Information System (MSIS)

FR Citation: 81 FR 25766

Number of Respondents: 4

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 40 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	404	-101	505
Annual IC Time Burden (Hours)	402	-100	502
Annual IC Cost Burden (Dollars)	20	-5	25

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.