Information Collection Request

National Coal Workers' Health Surveillance Program (CWHSP)

ICR 202501-0920-010 · OMB 0920-0020 · Historical Active

Forms and Documents

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

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
6620 Chest Radiograph Classification - B Reader Physician Form ModifiedChest Radiography
6620 Chest Radiograph Classification - B Reader Physician Form ModifiedChest Radiograph Classification
6620 Chest Radiograph Classification - B Reader Physician Form Modified
274684 B Reader for Physician Form NewPhysicians reporting outcomes of B Reader Examinations
274684 B Reader for Physician Form New
274683 Request for Medical Records Form NewRequest for Medcial Record
274683 Request for Medical Records Form New
250657 Pathologist Report Form ModifiedAuthorizaion for Payment of Autopsy
250657 Pathologist Report Form ModifiedAuthorization for Payment Autopsy
250657 Pathologist Report Form Modified
212093 Coal Contractor Plan CDC/NIOSH 2.18 Form ModifiedContractor Plan
212093 Coal Contractor Plan CDC/NIOSH 2.18 Form ModifiedCoal Contractor Plan
212093 Coal Contractor Plan CDC/NIOSH 2.18 Form Modified
212090 Spirometry Results Notification Form Form ModifiedSpirometry Results
212090 Spirometry Results Notification Form Form ModifiedSpirometry Results Notification form edit
212090 Spirometry Results Notification Form Form Modified
212089 Spirometry Facility Certification Form Form ModifiedSpirometry-Facility-Certification-Form
212089 Spirometry Facility Certification Form Form ModifiedSpirometry Facility Certification Form
212089 Spirometry Facility Certification Form Form Modified
212086 Respiratory Assessment Form - Spirometry Facility Employee Form ModifiedRespiratory Assessment Form
212086 Respiratory Assessment Form - Spirometry Facility Employee Form ModifiedRespiratory Assessment Form
212086 Respiratory Assessment Form - Spirometry Facility Employee Form Modified
197450 Coal Miner Radiograph (CWHSP) Form ModifiedChest Radiograph Classification
197450 Coal Miner Radiograph (CWHSP) Form ModifiedChest Radiograph Classification
197450 Coal Miner Radiograph (CWHSP) Form Modified
197449 Spirometry Test for Coal Miners Form ModifiedConsent Release and History Form
197449 Spirometry Test for Coal Miners Form ModifiedConsent, Release and History Form for Autopsy
197449 Spirometry Test for Coal Miners Form Modified
197448 Authorization for Payment of Autopsy Form ModifiedAuthorizaion for Payment of Autopsy
197448 Authorization for Payment of Autopsy Form ModifiedAuthorization for Payment of Autopsy
197448 Authorization for Payment of Autopsy Form Modified
197447 Invoice-Pathologist Form ModifiedAuthorizaion for Payment of Autopsy
197447 Invoice-Pathologist Form and Instruction ModifiedAuthorization for Payment of Autopsy
197447 Invoice-Pathologist Form and Instruction Modified
197446 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form and Instruction ModifiedConsent Release and History Form for Autopsy
197446 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form ModifiedConsent, Release and History Form for Autopsy
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 ModifiedPhysician Certifcation Document
183370 Physician Application for Certification (CDC/NIOSH 2.12) Form ModifiedPhysician Application for Certification
183370 Physician Application for Certification (CDC/NIOSH 2.12) Form Modified
183369 Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form ModifiedRadiographic Facility Certification Form
183369 Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form ModifiedRadiographic Facility Certification
183369 Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form Modified
183368 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form ModifiedOperators Plan
183368 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form ModifiedCoal Mine Operator's Plan
183368 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form Modified
183367 Miner Identification Document (CDC/NIOSH 2.9) Form ModifiedMiner Identification
183367 Miner Identification Document (CDC/NIOSH 2.9) Form ModifiedMiner Identification Document
183367 Miner Identification Document (CDC/NIOSH 2.9) Form Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
06/30/2028 36 Months From Approved
25,929 0 0
4,018 0 0
0 0 0





Reginfo record details
17
table that charts list of burden
IC Title Form No. Form Name
Coal Miner Radiograph (CWHSP) 0920-24IK, CDC/NIOSH 2.8(E), Revised 01/2020 ,  
Authorization for Payment of Autopsy 0920-24IK, CWHSP 2.19, Dec 2020 ,  
B Reader for Physician 0920-24IK
Chest Radiograph Classification - B Reader Physician 0920-0020-24IK, CDC/NIOSH (M) 2.8 REV 01/2020 ,  
Coal Contractor Plan CDC/NIOSH 2.18 0920-24IK, CDC/NIOSH (M) 2.18 (E), rev 01/2015 ,  
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) 0920-0020-24IK, CDC/NIOSH (M) 2.10 (E). rev 01/2015 ,  
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) 0920-24IK, CDC/NIOSH 2.6 (02/2015) ,  
Invoice-Pathologist 0920-24IK, CWHSP 2.19, Dec 2020 ,  
Miner Identification Document (CDC/NIOSH 2.9) 0920-0020-24IK, CDC/NIOSH 2.9(E), Revised 02/2019 ,  
Pathologist Report 0920-24IK, CWHSP 2.19, 12/2020 ,  
Physician Application for Certification (CDC/NIOSH 2.12) 0920-24IK, CDC 2.12 (E), Rev 02/2019 ,  
Radiographic Facility Certification (CDC/NIOSH (M) 2.11) 0920-24IK, CDC 2.11 (E), rev 02/2015 ,  
Request for Medical Records 0920-24IK
Respiratory Assessment Form - Spirometry Facility Employee 0920-24IK, CDC/NIOSH 2.13 (E), rev 04/2016 ,  
Spirometry Facility Certification Form 0920-24IK, CDC/NIOSH 2.14 (E), rev 06/2016 ,  
Spirometry Results Notification Form 0920-24IK, CDC/NIOSH 2.15 (E), rev 04/2015 ,  
Spirometry Test for Coal Miners 0920-24IK, CDC/NIOSH 2.6 (02/2015) ,  

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 25,929 0 0 -34,822 0 60,751
Annual Time Burden (Hours) 4,018 0 0 -7,735 0 11,753
Annual Cost Burden (Dollars) 0 0 0 -8 0 8


Reginfo record details
  No