Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)

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⚠️ Notice: This information collection may be referencing outdated material.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 2.6 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form
2.6 Consent, Release and History Form Attachment 19- Form 2.6.docx Form
2.6 Consent, Release and History Form Attachment 19- Form 2.6.docx Form

Information Collection (IC) Details

IC Title:	Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)	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	2.6	Consent, Release and History Form	Attachment 19- Form 2.6.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: 4	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4	3	1
Annual IC Time Burden (Hours)	1	1	0
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.