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

National Coal Workers' Health Surveillance Program (CWHSP)

Documents and Forms

Document Name Document Type
Form CDC/NIOSH 2.6 (02/ Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form
CDC/NIOSH 2.6 (02/ Consent, Release and History Form for Autopsy Att 19_NCWAS Consent, Release and Hist Form Form No. CDC NIOSH (M) 2.6.docx Form
CDC/NIOSH 2.6 (02/ Consent, Release and History Form for Autopsy Att 19_NCWAS Consent, Release and Hist Form Form No. CDC NIOSH (M) 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:	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/NIOSH 2.6 (02/2015)	Consent, Release and History Form for Autopsy	Att 19_NCWAS Consent, Release and Hist Form Form No. CDC NIOSH (M) 2.6.docx		Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-20-0153 Mortality Studies in Coal Mining	FR Citation: 51 FR 4247

Number of Respondents: 4	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	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.