National Coal Workers' Health Surveillance Program (CWHSP)

ICR 202501-0920-010

OMB: 0920-0020

Federal Form Document

Forms and Documents

Document Name	Status
Form CDC/NIOSH (M) 2.8 Chest Radiograph Classification - B Reader Physician Form	Modified
Form 0920-24IK B Reader for Physician Form	New
Form 0920-24IK Request for Medical Records Form	New
Form CWHSP 2.19, 12/202 Pathologist Report Form	Modified
Form CDC/NIOSH (M) 2.18 Coal Contractor Plan CDC/NIOSH 2.18 Form	Modified
Form CDC/NIOSH 2.15 (E) Spirometry Results Notification Form Form	Modified
Form CDC/NIOSH 2.14 (E) Spirometry Facility Certification Form Form	Modified
Form CDC/NIOSH 2.13 (E) Respiratory Assessment Form - Spirometry Facility Employee Form	Modified
Form CDC/NIOSH 2.8(E), Coal Miner Radiograph (CWHSP) Form	Modified
Form CDC/NIOSH 2.6 (02/ Spirometry Test for Coal Miners Form	Modified
Form CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Form	Modified
Form CWHSP 2.19, Dec 20 Invoice-Pathologist Form and Instruction	Modified
Form CDC/NIOSH 2.6 (02/ Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form	Modified
Form CDC 2.12 (E), Rev Physician Application for Certification (CDC/NIOSH 2.12) Form	Modified
Form CDC 2.11 (E), rev Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form	Modified
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form	Modified
Form CDC/NIOSH 2.9(E), Miner Identification Document (CDC/NIOSH 2.9) Form	Modified
Attachment 24 OCISO Standard Limiting use of SSN in CDC Infor Syst.docx Supplementary Document	2025-04-02
Attachment 26 IRB Approval.docx Supplementary Document	2025-04-02
Attachment 9_P01 Roster Letter to Miners.docx Supplementary Document	2025-04-02
Attachment 2_42 CFR Part 37 -- Specifications for Medical Examinations of Coal Miners.pdf Supplementary Document	2025-04-02
Attachment 1 Federal Mine Safety and Health Act of 1977.docx Supplementary Document	2025-04-02
Att 26_IRB Approval.docx Supplementary Document	2022-02-04
Att 25_OCISO Approval for the Collection of PII.docx Supplementary Document	2022-02-04
Att 24_OCISO Standard Limiting use of SSN in CDC Infor Syst.docx Supplementary Document	2022-02-04
Att 23_Contact Information for Stakeholders.docx Supplementary Document	2022-02-04
Attachment 2b- 60day FRN.pdf Supplementary Document	2022-02-04
SSB_0920-0020_2025 ReInstmnt_FINAL.docx Supporting Statement B	2025-04-02
SSA_0920-0020_2025 ReINSTAMENT_4225.docx Supporting Statement A	2025-04-02
Attachment 2a.pdf Supplementary Document	2021-12-02
Attachment 1 Authorizing Authority.docx Supplementary Document	2021-12-13

IC Document Collections

IC ID	Document Title	Status
6620	Chest Radiograph Classification - B Reader Physician Form	Modified
274684	B Reader for Physician Form	New
274683	Request for Medical Records Form	New
250657	Pathologist Report Form	Modified
212093	Coal Contractor Plan CDC/NIOSH 2.18 Form	Modified
212090	Spirometry Results Notification Form Form	Modified
212089	Spirometry Facility Certification Form Form	Modified
212086	Respiratory Assessment Form - Spirometry Facility Employee Form	Modified
197450	Coal Miner Radiograph (CWHSP) Form	Modified
197449	Spirometry Test for Coal Miners Form	Modified
197448	Authorization for Payment of Autopsy Form	Modified
197447	Invoice-Pathologist Form and Instruction	Modified
197446	Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form	Modified
183370	Physician Application for Certification (CDC/NIOSH 2.12) Form	Modified
183369	Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form	Modified
183368	Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form	Modified
183367	Miner Identification Document (CDC/NIOSH 2.9) Form	Modified