Physician Application for Certification (CDC/NIOSH 2.12)

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⚠️ Notice: This information collection may be referencing outdated material.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
Form 2.12 Physician Application for Certification (CDC/NIOSH 2.12) Form and Instruction
2.12 Physician Application for Certification Attachment 12- Form 2.12.docx Form and Instruction
2.12 Physician Application for Certification Attachment 12- Form 2.12.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Physician Application for Certification (CDC/NIOSH 2.12)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Form and Instruction	2.12	Physician Application for Certification	Attachment 12- Form 2.12.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: Morbidity Studies in Coal Mining, Metal and Non-metal Mining and General Industry	FR Citation: 51 FR 42476

Number of Respondents: 220	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	220	140	80
Annual IC Time Burden (Hours)	37	24	13
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.