Physician Application for Certification (CDC/NIOSH 2.12)

National Coal Workers' Health Surveillance Program (CWHSP)

Documents and Forms

Document Name Document Type
Form CDC 2.12 (E), Rev Physician Application for Certification (CDC/NIOSH 2.12) Form
CDC 2.12 (E), Rev Physician Application for Certification Attachment 12 Physician Application for Cert Form No. CDC NIOSH (M) 2.12.docx Form
CDC 2.12 (E), Rev Physician Application for Certification Attachment 12 Physician Application for Cert Form No. CDC NIOSH (M) 2.12.docx Form

Information Collection (IC) Details

IC Title:	Physician Application for Certification (CDC/NIOSH 2.12)	Agency IC Tracking Number:	0920-0020

Is this a Common Form? No		IC Status: Modified

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	CDC 2.12 (E), Rev 02/2019	Physician Application for Certification	Attachment 12 Physician Application for Cert Form No. CDC NIOSH (M) 2.12.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: 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 %

	Approved	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.