National Coal Workers' Health Surveillance Program (CWHSP)

Forms and Documents

Forms and supporting documents for this ICR

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

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6620	B Reader Chest Radiograph Classification (CDC/NIOSH Form 2.8)	Form	Modified	Chest radiographic classification form
6620	B Reader Chest Radiograph Classification (CDC/NIOSH Form 2.8)	Form	Modified
247601	Authorization for Payment of Autopsy	Form	New	Authorization for Payment of Autopsy
247601	Authorization for Payment of Autopsy	Form	New
212093	Coal Contractor Plan (CDC/NIOSH 2.18)	Form	Modified	Coal contractor plan
212093	Coal Contractor Plan (CDC/NIOSH 2.18)	Form	Modified
212090	Spirometry Results Notification (CDC/NIOSH 2.15)	Form	Modified	Spirometry Results Notification
212090	Spirometry Results Notification (CDC/NIOSH 2.15)	Form	Modified
212089	Spirometry Facility Supervisor - Certification Document 2.14	Form	Modified	Spirometry Facility Certification
212089	Spirometry Facility Supervisor - Certification Document 2.14	Form	Modified
212086	Spirometry Facility Employee - Respiratory Assessment 2.13	Form	Modified	Respiratory assessment
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	Consent, Release and History Form
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	Physician Application for Certification
183370	Physician Application for Certification (CDC/NIOSH 2.12)	Form and Instruction	Modified
183369	Radiographic Facility Certification (CDC/NIOSH 2.11)	Form	Modified	Radiograph Facility Certification
183369	Radiographic Facility Certification (CDC/NIOSH 2.11)	Form	Modified
183368	Coal Mine Operator's Plan (CDC/NIOSH 2.10)	Form	Modified	Coal mine operator form
183368	Coal Mine Operator's Plan (CDC/NIOSH 2.10)	Form	Modified
183367	Miner Identification Document (CDC/NIOSH 2.9)	Form	Modified	Miner identification form
183367	Miner Identification Document (CDC/NIOSH 2.9)	Form	Modified

ICR Details

OMB Control No: 0920-0020	ICR Reference No: 202105-0920-011
Status: Historical Inactive	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
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 08/13/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/25/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2021	36 Months From Approved	09/30/2021
Responses	104,126	0	104,126
Time Burden (Hours)	20,274	0	20,274
Cost Burden (Dollars)	0	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

table that charts list of burden

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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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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