Spirometry Test for Coal Miners

National Coal Workers' Health Surveillance Program (CWHSP)

Documents and Forms

Document Name Document Type
Form CDC/NIOSH 2.6 (02/ Spirometry Test for Coal Miners Form
CDC/NIOSH 2.6 (02/ Consent, Release and History Form for Autopsy Attachment 19 NCWAS Consent, Release and Hist Form Form No. CDC NIOSH (M) 2.6.docx Form
0920-24IK Consent Release and History Form Attachment 19_Consent Release and History Form for Autopsy 01 2015_FILLABLE (2.6).pdf Form
Attachment 18 Sample Letter to Participating Miners_ Spiro Exam Results.docx Sample Letter (Spirometry Examination results) IC Document
Attachment 18_Sample Spiro Results Notification Letter BLANK.PDF Sample Spiro Results Notification IC Document

Information Collection (IC) Details

IC Title:	Spirometry Test for Coal Miners	Agency IC Tracking Number:	0920-0020-24IK

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC/NIOSH 2.6 (02/2015)	Consent, Release and History Form for Autopsy	Attachment 19 NCWAS Consent, Release and Hist Form Form No. CDC NIOSH (M) 2.6.docx		Yes	Yes	Fillable Fileable Signable
Form	0920-24IK	Consent Release and History Form	Attachment 19_Consent Release and History Form for Autopsy 01 2015_FILLABLE (2.6).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0153 Mortality Studies in Coal Mining	FR Citation: 51 FR 42476

Number of Respondents: 619	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	619	-7,881	8,500
Annual IC Time Burden (Hours)	155	-1,970	2,125
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Sample Letter (Spirometry Examination results)	Attachment 18 Sample Letter to Participating Miners_ Spiro Exam Results.docx	02/04/2022
Sample Spiro Results Notification	Attachment 18_Sample Spiro Results Notification Letter BLANK.PDF	04/02/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.