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⚠️ Notice: This information collection may be referencing outdated material.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 2.12_Form_Physician Application for Certification 2.12_Removedcitydate.docx Form and Instruction
2.12 Physician Application for Certification 2.12_Form_Physician Application for Certification 2.12_Removedcitydate.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: Unchanged

Obligation to Respond: Mandatory

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	2.12_Form_Physician Application for Certification 2.12_Removedcitydate.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0149-Morbidity Studies in Coal Mining, Metal and Non-Metal Mining and General Industry and 0920-0153- Mortality Studies in coal Mining, Metal and Non-Metal Mining and General Industry.	FR Citation: 51 FR 42476

Number of Respondents: 80	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	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.