Spirometry Facility Certification Form

National Coal Workers' Health Surveillance Program (CWHSP)

Documents and Forms

Document Name Document Type
Form CDC/NIOSH 2.14 (E) Spirometry Facility Certification Form Form
CDC/NIOSH 2.14 (E) Spirometry Facility Certification Form Attachment 15 Spiro Facility Cert Doc Form No. CDC NIOSH_(M) 2.14.docx Form
CDC/NIOSH 2.14 (E) Spirometry Facility Certification Form Attachment 15 Spiro Facility Cert Doc Form No. CDC NIOSH_(M) 2.14.docx Form
Attachment 13 Sample Letters to Physicians rept outcomes of B Reader Exam.docx Physician Reporting B Reader Exam Outcomes- Sample Letter IC Document
Attachment 13 Sample Letters to Physicians rept outcomes of B Reader Exam.docx Physician Reporting B Reader Exam Outcomes- Sample Letter IC Document

Information Collection (IC) Details

IC Title:	Spirometry Facility Certification Form	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 2.14 (E), rev 06/2016	Spirometry Facility Certification Form	Attachment 15 Spiro Facility Cert Doc Form No. CDC NIOSH_(M) 2.14.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Mortality Studies in Coal Mining, Metal and Non-Metal Mining and General Industry – 09-20-0153	FR Citation: 51 FR 42478

Number of Respondents: 15	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	15	-85	100
Annual IC Time Burden (Hours)	8	-42	50
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Physician Reporting B Reader Exam Outcomes- Sample Letter	Attachment 13 Sample Letters to Physicians rept outcomes of B Reader Exam.docx	02/04/2022

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