National Coal Workers' Health Surveillance Program (CWHSP)

ICR 202507-0920-012

OMB: 0920-0020

Federal Form Document

Forms and Documents
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Justification for No Material/Nonsubstantive Change
2025-07-15
Supplementary Document
2025-04-02
Supplementary Document
2025-04-02
Supplementary Document
2025-04-02
Supplementary Document
2025-04-02
Supplementary Document
2025-04-02
Supplementary Document
2022-02-04
Supplementary Document
2022-02-04
Supplementary Document
2022-02-04
Supplementary Document
2022-02-04
Supplementary Document
2022-02-04
Supporting Statement B
2025-04-02
Supporting Statement A
2025-04-02
Supplementary Document
2021-12-02
Supplementary Document
2021-12-13
ICR Details
0920-0020 202507-0920-012
Active 202501-0920-010
HHS/CDC 0920-0020-24IK
National Coal Workers' Health Surveillance Program (CWHSP)
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 07/17/2025
Retrieve Notice of Action (NOA) 07/17/2025
  Inventory as of this Action Requested Previously Approved
06/30/2028 06/30/2028 06/30/2028
25,929 0 25,929
4,018 0 4,018
0 0 0

The Coal Workers' Health Surveillance Program (CWHSP) is a congressionally-mandated medical examination surveillance program for monitoring the health of coal miners. This program, which operates in accordance with 42 CFR Part 37, is useful in providing information to protect the health of coal miners and to document trends and patterns in the prevalence of coal workers' pneumoconiosis (`black lung' disease) among miners employed in U.S. coal mines. Non-Substantive Change Request is submitted to make minor updates to Medical Records Request Form. There are no changes to approved burden hours associated with this request.

PL: Pub.L. 91 - 173 203 Name of Law: Federal Coal Mine Health and Safety Act
   PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health Act
   US Code: 42 USC 37 Name of Law: Specifications for Medical Exam of Coal Miners
  
None

Not associated with rulemaking

  89 FR 71273 09/30/2024
90 FR 14452 04/01/2025
No

17
IC Title Form No. Form Name
Coal Miner Radiograph (CWHSP) CDC/NIOSH 2.8(E), Revised 01/2020, 0920-24IK Chest Radiograph Classification ,   Chest Radiograph Classification
Authorization for Payment of Autopsy CWHSP 2.19, Dec 2020, 0920-24IK Authorization for Payment of Autopsy ,   Authorizaion for Payment of Autopsy
B Reader for Physician 0920-24IK Physicians reporting outcomes of B Reader Examinations
Chest Radiograph Classification - B Reader Physician CDC/NIOSH (M) 2.8 REV 01/2020, 0920-0020-24IK Chest Radiograph Classification ,   Chest Radiography
Coal Contractor Plan CDC/NIOSH 2.18 CDC/NIOSH (M) 2.18 (E), rev 01/2015, 0920-24IK Coal Contractor Plan ,   Contractor Plan
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) CDC/NIOSH (M) 2.10 (E). rev 01/2015, 0920-0020-24IK Coal Mine Operator's Plan ,   Operators Plan
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) CDC/NIOSH 2.6 (02/2015), 0920-24IK Consent, Release and History Form for Autopsy ,   Consent Release and History Form for Autopsy
Invoice-Pathologist CWHSP 2.19, Dec 2020, 0920-24IK Authorization for Payment of Autopsy ,   Authorizaion for Payment of Autopsy
Miner Identification Document (CDC/NIOSH 2.9) CDC/NIOSH 2.9(E), Revised 02/2019, 0920-0020-24IK Miner Identification Document ,   Miner Identification
Pathologist Report CWHSP 2.19, 12/2020, 0920-24IK Authorization for Payment Autopsy ,   Authorizaion for Payment of Autopsy
Physician Application for Certification (CDC/NIOSH 2.12) CDC 2.12 (E), Rev 02/2019, 0920-24IK Physician Application for Certification ,   Physician Certifcation Document
Radiographic Facility Certification (CDC/NIOSH (M) 2.11) CDC 2.11 (E), rev 02/2015, 0920-24IK Radiographic Facility Certification ,   Radiographic Facility Certification Form
Request for Medical Records 0920-24IK, 0920-0020 Request for Medcial Record ,   Medical Records Request Form - revised 15JUL2025
Respiratory Assessment Form - Spirometry Facility Employee CDC/NIOSH 2.13 (E), rev 04/2016, 0920-24IK Respiratory Assessment Form ,   Respiratory Assessment Form
Spirometry Facility Certification Form CDC/NIOSH 2.14 (E), rev 06/2016, 0920-24IK Spirometry Facility Certification Form ,   Spirometry-Facility-Certification-Form
Spirometry Results Notification Form CDC/NIOSH 2.15 (E), rev 04/2015, 0920-24IK Spirometry Results Notification form edit ,   Spirometry Results
Spirometry Test for Coal Miners CDC/NIOSH 2.6 (02/2015), 0920-24IK Consent, Release and History Form for Autopsy ,   Consent Release and History Form

  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 25,929 0 0 0 0
Annual Time Burden (Hours) 4,018 4,018 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$2,699,239
Yes Part B of Supporting Statement
    Yes
    Yes
No
No
No
No
Jeffrey Zirger 404 639-7118 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/17/2025


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