Information Collection

Physician Application for Certification (CDC/NIOSH 2.12)

IC 183370 under ICR 202111-0920-021 · OMB 0920-0020.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0020 can be found here:

Documents and Forms

Documents and forms in this information collection
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

View Information Collection (IC)

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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
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.