Pathologist Report

National Coal Workers' Health Surveillance Program (CWHSP)

Documents and Forms

Document Name Document Type
Form CWHSP 2.19, 12/202 Pathologist Report Form
CWHSP 2.19, 12/202 Authorization for Payment Autopsy Attachment 22 Auth for Pay of Autopsy Form No. CDC NIOSH (M) 2.19.pdf Form
CWHSP 2.19, 12/202 Authorization for Payment Autopsy Attachment 22 Auth for Pay of Autopsy Form No. CDC NIOSH (M) 2.19.pdf Form
Attachment 20 42 CFR 37.202 Autopsy Invoice - Sample.docx Autospy Invoice - Sample IC Document
Attachment 20 42 CFR 37.202 Autopsy Invoice - Sample.docx Autospy Invoice - Sample IC Document
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

Information Collection (IC) Details

IC Title:	Pathologist Report	Agency IC Tracking Number:	0920-0020

Is this a Common Form? No		IC Status: New

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, 12/2020	Authorization for Payment 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:	FR Citation:

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

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	4	4
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	4	4

Documents for IC

Title	Document	Date Uploaded
Autospy Invoice - Sample	Attachment 20 42 CFR 37.202 Autopsy Invoice - Sample.docx	02/04/2022
Pathologist Report of Autopsy - Sample	Attachment 21 42 CFR 37.203 Path Report of Autopsy - Sample.docx	02/04/2022

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