Black Lung Clinics Program Measures

Documents and Forms

Document Name Document Type
Form 1 Black Lung Clinics Program Measures Form
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

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	BLCP Measure Instrument	BLCP Measure Instrument 10152024_Clean version 11.21.24.docx		Yes	Yes	Fillable Fileable
Form and Instruction	1_Redline	BLCP Measure Instrument_Redline	BLCP Measure Instrument 10152024_OMB Comment Updates_11.18.24.docx		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 %

	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

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.