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⚠️ Notice: This information collection may be referencing outdated material.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