Information Collection

Black Lung Clinics Program Measures

IC 6545 under ICR 202410-0915-002 · OMB 0915-0292.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0292 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Black Lung Clinics Program Measures	Form
Form 1 BLCP Measure Instrument Black Lung Clinics Program Measures	Form
Form 1_Redline BLCP Measure Instrument_Redline Black Lung Clinics Program Measures	Form and Instruction
1 BLCP Measure Instrument BLCP Measure Instrument 10152024.docx	Form
1 BLCP Measure Instrument BLCP Measure Instrument 10152024_Clean version 11.21.24.docx	Form
1_Redline BLCP Measure Instrument_Redline BLCP Measure Instrument 10152024_OMB Comment Updates_11.18.24.docx	Form and Instruction

IC Title:

Black Lung Clinics Program Measures

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	1				Yes	Yes	Fillable Fileable
Form and Instruction	1_Redline				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 15

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	15	0	15
Annual IC Time Burden (Hours)	105	-45	150
Annual IC Cost Burden (Dollars)	0	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.

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