Information Collection

Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....

IC 13765 under ICR 202401-1240-006 · OMB 1240-0023.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-933 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form
Form CM-933 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Form
CM-933 Radiologic Interpretation CM-933-Form Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-933 Radiologic Interpretation CM-933-Form Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-933b Radiologic Quality Rereading CM-933b Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-933b Radiologic Quality Rereading CM-933b Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-988 Medical History and Examination for Coal Mine Workers’ P CM-988 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-988 Medical History and Examination for Coal Mine Workers’ P CM-988 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-1159 Report of Arterial Blood Gas Study CM-1159 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-1159 Report of Arterial Blood Gas Study CM-1159 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-2907 Report of Ventilatory Study CM-2907 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-2907 Report of Ventilatory Study CM-2907 Non-Sub.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 718.202 20 CFR 725.406 20 CFR 718.204 20 CFR 718.102-105

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	CM-933	Radiologic Interpretation	CM-933-Form Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-933b	Radiologic Quality Rereading	CM-933b Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-988	Medical History and Examination for Coal Mine Workersâ Pneumoconiosis	CM-988 Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-1159	Report of Arterial Blood Gas Study	CM-1159 Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable
Form	CM-2907	Report of Ventilatory Study	CM-2907 Non-Sub.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-2 and DOL/OWCP-9

FR Citation: 67 FR 16869

Number of Respondents: 21,500

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	Previously Approved
Annual Number of Responses for this IC	21,500	21,500
Annual IC Time Burden (Hours)	5,232	5,232
Annual IC Cost Burden (Dollars)	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.