OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

ICR 202111-0920-021 · OMB 0920-0020 · Public filing

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CDC/NIOSH (M) 2.8 Chest Radiograph Classification Form Modified Available
Form CDC/NIOSH (M) 2.8 Chest Radiograph Classification - B Reader Physician Form Modified Repair queued
Form CWHSP 2.19, 12/202 Authorization for Payment Autopsy Form New Available
Form CWHSP 2.19, 12/202 Pathologist Report Form New Repair queued
Form CDC/NIOSH (M) 2.18 Coal Contractor Plan Form Modified Repair queued
Form CDC/NIOSH (M) 2.18 Coal Contractor Plan CDC/NIOSH 2.18 Form Modified Repair queued
Form CDC/NIOSH 2.15 (E) Spirometry Results Notification form edit Form Modified Available
Form CDC/NIOSH 2.15 (E) Spirometry Results Notification Form Form Modified Repair queued
Form CDC/NIOSH 2.14 (E) Spirometry Facility Certification Form Form Modified Available
Form CDC/NIOSH 2.14 (E) Spirometry Facility Certification Form Form Modified Repair queued
Form CDC/NIOSH 2.13 (E) Respiratory Assessment Form Form Modified Available
Form CDC/NIOSH 2.13 (E) Respiratory Assessment Form - Spirometry Facility Employee Form Modified Repair queued
Form CDC/NIOSH 2.8(E), Chest Radiograph Classification Form Modified Available
Form CDC/NIOSH 2.8(E), Coal Miner Radiograph (CWHSP) Form Modified Repair queued
Form CDC/NIOSH 2.6 (02/ Consent, Release and History Form for Autopsy Form Modified Available
Form CDC/NIOSH 2.6 (02/ Spirometry Test for Coal Miners Form Modified Repair queued
Form CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Form Modified Available
Form CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Form Modified Repair queued
Form CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Form and Instruction Modified Available
Form CWHSP 2.19, Dec 20 Invoice-Pathologist Form and Instruction Modified Repair queued
Form CDC/NIOSH 2.6 (02/ Consent, Release and History Form for Autopsy Form Modified Repair queued
Form CDC/NIOSH 2.6 (02/ Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form Modified Repair queued
Form CDC 2.12 (E), Rev Physician Application for Certification Form Modified Available
Form CDC 2.12 (E), Rev Physician Application for Certification (CDC/NIOSH 2.12) Form Modified Repair queued
Form CDC 2.11 (E), rev Radiographic Facility Certification Form Modified Available
Form CDC 2.11 (E), rev Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form Modified Repair queued
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan Form Modified Available
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form Modified Repair queued
Form CDC/NIOSH 2.9(E), Miner Identification Document Form Modified Repair queued
Form CDC/NIOSH 2.9(E), Miner Identification Document (CDC/NIOSH 2.9) Form Modified Repair queued
Att 26_IRB Approval.docx Supplementary Document Uploaded 2022-02-04 Repair queued
Att 25_OCISO Approval for the Collection of PII.docx Supplementary Document Uploaded 2022-02-04 Available
Att 24_OCISO Standard Limiting use of SSN in CDC Infor Syst.docx Supplementary Document Uploaded 2022-02-04 Repair queued
Att 23_Contact Information for Stakeholders.docx Supplementary Document Uploaded 2022-02-04 Repair queued
Attachment 2b- 60day FRN.pdf Supplementary Document Uploaded 2022-02-04 Repair queued
SSB_11.15.21.docx Supporting Statement B Uploaded 2022-01-25 Repair queued
SSA_12.17.21.docm Supporting Statement A Uploaded 2022-01-25 Repair queued
Attachment 2a.pdf Supplementary Document Uploaded 2021-12-02 Repair queued
Attachment 1 Authorizing Authority.docx Supplementary Document Uploaded 2021-12-13 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
6620 Chest Radiograph Classification - B Reader Physician Form ModifiedChest Radiograph Classification
6620 Chest Radiograph Classification - B Reader Physician Form Modified
250657 Pathologist Report Form NewAuthorization for Payment Autopsy
250657 Pathologist Report Form New
212093 Coal Contractor Plan CDC/NIOSH 2.18 Form ModifiedCoal Contractor Plan
212093 Coal Contractor Plan CDC/NIOSH 2.18 Form Modified
212090 Spirometry Results Notification Form Form ModifiedSpirometry Results Notification form edit
212090 Spirometry Results Notification Form Form Modified
212089 Spirometry Facility Certification Form Form ModifiedSpirometry Facility Certification Form
212089 Spirometry Facility Certification Form Form Modified
212086 Respiratory Assessment Form - Spirometry Facility Employee Form ModifiedRespiratory Assessment Form
212086 Respiratory Assessment Form - Spirometry Facility Employee Form Modified
197450 Coal Miner Radiograph (CWHSP) Form ModifiedChest Radiograph Classification
197450 Coal Miner Radiograph (CWHSP) Form Modified
197449 Spirometry Test for Coal Miners Form ModifiedConsent, Release and History Form for Autopsy
197449 Spirometry Test for Coal Miners Form Modified
197448 Authorization for Payment of Autopsy Form ModifiedAuthorization for Payment of Autopsy
197448 Authorization for Payment of Autopsy Form Modified
197447 Invoice-Pathologist Form and Instruction ModifiedAuthorization for Payment of Autopsy
197447 Invoice-Pathologist Form and Instruction Modified
197446 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form ModifiedConsent, Release and History Form for Autopsy
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 ModifiedPhysician Application for Certification
183370 Physician Application for Certification (CDC/NIOSH 2.12) Form Modified
183369 Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form ModifiedRadiographic Facility Certification
183369 Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form Modified
183368 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form ModifiedCoal Mine Operator's Plan
183368 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form Modified
183367 Miner Identification Document (CDC/NIOSH 2.9) Form ModifiedMiner Identification Document
183367 Miner Identification Document (CDC/NIOSH 2.9) Form Modified

ICR Details

Record metadata
OMB Control No0920-0020