Information Collection

Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....

IC 13765 under ICR 202005-1240-001 · OMB 1240-0023.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0023 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-988 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form and Instruction
CM-933 Radiologic Interpretation 20200430 CM-933.docx www.dol.gov/owcp/regs/compliance/cm-933.pdf	Form and Instruction
CM-933b Radiologic Quality Rereading 20200430 CM-933b.docx www.dol.gov/owcp/regs/compliance/cm-933b.pdf	Form and Instruction
CM-1159 Report of Arterial Blood Gas Test 20200430 CM-1159.docx wwwldol.gov/owcp/regs/compliance/cm-1159.pdf	Form and Instruction
CM-2907 Report of Ventilatory Study 20200430 CM-2907.docx www.dol.gov/owcp/regs/compliance/cm-2907.pdf	Form and Instruction
CM-988 Medical History and Examination for Coal Mine Workers Pn 1240-0023 Medical History and Examination for Coal Mine Workers Pneumoconiosis (CM-988).pdf www.dol.gov/owcp/regs/compliance/cm-988cm-988a.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 718.102-105 20 CFR 725.406 20 CFR 718.202 20 CFR 718.204

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	CM-988	Medical History and Examination for Coal Mine Workers Pneumoconiosis	1240-0023 Medical History and Examination for Coal Mine Workers Pneumoconiosis (CM-988).pdf	http://www.dol.gov/owcp/regs/compliance/cm-988cm-988a.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-933	Radiologic Interpretation	20200430 CM-933.docx	http://www.dol.gov/owcp/regs/compliance/cm-933.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-933b	Radiologic Quality Rereading	20200430 CM-933b.docx	http://www.dol.gov/owcp/regs/compliance/cm-933b.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-1159	Report of Arterial Blood Gas Test	20200430 CM-1159.docx	http://wwwldol.gov/owcp/regs/compliance/cm-1159.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-2907	Report of Ventilatory Study	20200430 CM-2907.docx	http://www.dol.gov/owcp/regs/compliance/cm-2907.pdf	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-2 and DOL/OWCP-9

FR Citation: 67 FR 16869

Number of Respondents: 30,000

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	Previously Approved
Annual Number of Responses for this IC	30,000	2,500	27,500
Annual IC Time Burden (Hours)	7,300	607	6,693
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.