Spirometry Results Notification Form

National Coal Workers' Health Surveillance Program (CWHSP)

Documents and Forms

Document Name Document Type
Form CDC/NIOSH 2.15 (E) Spirometry Results Notification Form Form
CDC/NIOSH 2.15 (E) Spirometry Results Notification form edit Attachment 17 Spiro Results Notification Form Form No. CDC NIOSH (M) 2.15.docx Form
0920-24IK Spirometry Results Attachment 17 Spirometry-Results-Notification- Form (2.15)_REVISED 02192025.pdf Form
Attachment 18 Sample Letter to Participating Miners_ Spiro Exam Results.docx Spirometry Examination Results -- Sample Letter IC Document

Information Collection (IC) Details

IC Title:	Spirometry Results Notification Form	Agency IC Tracking Number:	0920-0020-24IK

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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 2.15 (E), rev 04/2015	Spirometry Results Notification form edit	Attachment 17 Spiro Results Notification Form Form No. CDC NIOSH (M) 2.15.docx	NA	Yes	Yes	Fillable Fileable
Form	0920-24IK	Spirometry Results	Attachment 17 Spirometry-Results-Notification- Form (2.15)_REVISED 02192025.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Mortality Studies in Coal Mining, Metal and Non-Metal Mining and General Industry – 09-20-0153	FR Citation: 51 FR 42478

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

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	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)	206	-2,627	2,833
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Spirometry Examination Results -- Sample Letter	Attachment 18 Sample Letter to Participating Miners_ Spiro Exam Results.docx	02/04/2022

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