National Coal Workers' Health Surveillance Program (CWHSP)

Forms and Documents

Document Name	Status
Form 2..8 B Reader Chest Radiograph Classification (CDC/NIOSH Form 2.8) Form	Modified
Form 2.19 Authorization for Payment of Autopsy Form	New
Form 2.18 Coal Contractor Plan (CDC/NIOSH 2.18) Form	Modified
Form 2.15 Spirometry Results Notification (CDC/NIOSH 2.15) Form	Modified
Form 2.14 Spirometry Facility Supervisor - Certification Document 2.14 Form	Modified
Form 2.13 Spirometry Facility Employee - Respiratory Assessment 2.13 Form	Modified
Form 2.6 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form	Modified
Form 2.12 Physician Application for Certification (CDC/NIOSH 2.12) Form and Instruction	Modified
Form 2.11 Radiographic Facility Certification (CDC/NIOSH 2.11) Form	Modified
Form 2.10 Coal Mine Operator's Plan (CDC/NIOSH 2.10) Form	Modified
Form 2.9 Miner Identification Document (CDC/NIOSH 2.9) Form	Modified
Attachment 26- IRB approval.docx Supplementary Document	2021-05-24
Attachment 25- OCISO PII approval.docx Supplementary Document	2021-05-24
Attachment 24- OCISO SSN standard.docx Supplementary Document	2021-05-24
Attachment 23- Stakeholders contact info.docx Supplementary Document	2021-05-24
Attachment 18- Sample letter- Miners exam results.docx Supplementary Document	2021-05-24
Attachment 14 Sample letters- B Readers recertification exam.docx Supplementary Document	2021-05-24
Attachment 13 Sample letters-B Reader test results.docx Supplementary Document	2021-05-24
Attachment 10 Sample results letter.docx Supplementary Document	2021-05-24
Attachment 9 Sample letter- participation.docx Supplementary Document	2021-05-24
Attachment 7 Sample letter to Radiographic facility.docx Supplementary Document	2021-05-24
Attachment 5 Sample Letters.docx Supplementary Document	2021-05-24
Attachment 2a- NPRM.pdf Supplementary Document	2021-05-24
Attachment 1 Authorizing Authority.docx Supplementary Document	2021-05-24
SupSta B_0920-0020.docx Supporting Statement B	2021-05-24
Supporting statement A_11.19.20.docx Supporting Statement A	2021-05-24
Request for Nonsubstantive Changes OMB #0920-0020_2021MAR17.docx Justification for No Material/Nonsubstantive Change	2021-04-22

IC Document Collections

IC ID	Document Title	Status
6620	B Reader Chest Radiograph Classification (CDC/NIOSH Form 2.8) Form	Modified
247601	Authorization for Payment of Autopsy Form	New
212093	Coal Contractor Plan (CDC/NIOSH 2.18) Form	Modified
212090	Spirometry Results Notification (CDC/NIOSH 2.15) Form	Modified
212089	Spirometry Facility Supervisor - Certification Document 2.14 Form	Modified
212086	Spirometry Facility Employee - Respiratory Assessment 2.13 Form	Modified
197450	Coal Miner Radiograph (CWHSP) Instruction	Modified
197449	Spirometry Test for Coal Miners Instruction	Modified
197448	Report - Pathologist Instruction	Modified
197447	Invoice-Pathologist Instruction	Modified
197446	Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form	Modified
183370	Physician Application for Certification (CDC/NIOSH 2.12) Form and Instruction	Modified
183369	Radiographic Facility Certification (CDC/NIOSH 2.11) Form	Modified
183368	Coal Mine Operator's Plan (CDC/NIOSH 2.10) Form	Modified
183367	Miner Identification Document (CDC/NIOSH 2.9) Form	Modified

ICR Details

OMB Control No: 0920-0020	ICR Reference No: 202105-0920-011
Status: Received in OIRA	Previous ICR Reference No: 202104-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0020
Title: National Coal Workers' Health Surveillance Program (CWHSP)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/25/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	09/30/2021
Responses	60,751	104,126
Time Burden (Hours)	11,753	20,274
Cost Burden (Dollars)	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. This revision adds a form to allow for compensation for pathologists.

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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:
	85 FR 8521	02/14/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 24336	05/06/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

IC Title	Form No.	Form Name
Coal Miner Radiograph (CWHSP)
Authorization for Payment of Autopsy	2.19	Authorization for Payment of Autopsy
B Reader Chest Radiograph Classification (CDC/NIOSH Form 2.8)	2..8	Chest radiographic classification form
Coal Contractor Plan (CDC/NIOSH 2.18)	2.18	Coal contractor plan
Coal Mine Operator's Plan (CDC/NIOSH 2.10)	2.10	Coal mine operator form
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)	2.6	Consent, Release and History Form
Invoice-Pathologist
Miner Identification Document (CDC/NIOSH 2.9)	2.9	Miner identification form
Physician Application for Certification (CDC/NIOSH 2.12)	2.12	Physician Application for Certification
Radiographic Facility Certification (CDC/NIOSH 2.11)	2.11	Radiograph Facility Certification
Report - Pathologist
Spirometry Facility Employee - Respiratory Assessment 2.13	2.13	Respiratory assessment
Spirometry Facility Supervisor - Certification Document 2.14	2.14	Spirometry Facility Certification
Spirometry Results Notification (CDC/NIOSH 2.15)	2.15	Spirometry Results Notification
Spirometry Test for Coal Miners

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ICR Summary of Burden

	Total Request	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	60,751	104,126	0	-43,375	0	0
Annual Time Burden (Hours)	11,753	20,274	0	-8,521	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This revision includes the addition of a form for authorization for payment for autopsy, as well as adjustments to the number of respondents resulting in burden decreases.

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Annual Cost to Federal Government: $2,699,239

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.     Yes

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? No

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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: 05/25/2021

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