Authorization for Payment of Autopsy

National Coal Workers' Health Surveillance Program (CWHSP)

Documents and Forms

Document Name Document Type
Form CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Form
CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Attachment 22 Auth for Pay of Autopsy Form No. CDC NIOSH (M) 2.19.pdf Form
CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Attachment 22 Auth for Pay of Autopsy Form No. CDC NIOSH (M) 2.19.pdf Form
Attachment 21 42 CFR 37.203 Path Report of Autopsy - Sample.docx Pathologist Report of Autopsy -- Sample IC Document
Attachment 21 42 CFR 37.203 Path Report of Autopsy - Sample.docx Pathologist Report of Autopsy -- Sample IC Document
Attachment 20 .docx Autopsy Invoice Sample IC Document
Attachment 20 .docx Autopsy Invoice Sample IC Document

Information Collection (IC) Details

IC Title:	Authorization for Payment of Autopsy	Agency IC Tracking Number:	0920-0020

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CWHSP 2.19, Dec 2020	Authorization for Payment of Autopsy	Attachment 22 Auth for Pay of Autopsy Form No. CDC NIOSH (M) 2.19.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0149 Mortality in Coal Miners	FR Citation: 51 FR 42746

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

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

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
Pathologist Report of Autopsy -- Sample	Attachment 21 42 CFR 37.203 Path Report of Autopsy - Sample.docx	02/04/2022
Autopsy Invoice Sample	Attachment 20 .docx	11/29/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.