Information Collection Request

National Coal Workers' Health Surveillance Program (CWHSP)

ICR 202507-0920-012 · OMB 0920-0020 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-0020-24IK Chest Radiography Form Unchanged Available
Form CDC/NIOSH (M) 2.8 Chest Radiograph Classification Form Unchanged Available
Form 0920-24IK Physicians reporting outcomes of B Reader Examinations Form Unchanged Available
Form 0920-0020 Medical Records Request Form - revised 15JUL2025 Form Modified Available
Form 0920-24IK Request for Medcial Record Form Modified Available
Form 0920-24IK Authorizaion for Payment of Autopsy Form Unchanged Available
Form CWHSP 2.19, 12/202 Authorization for Payment Autopsy Form Unchanged Available
Form 0920-24IK Contractor Plan Form Unchanged Available
Form CDC/NIOSH (M) 2.18 Coal Contractor Plan Form Unchanged Available
Form 0920-24IK Spirometry Results Form Unchanged Available
Form CDC/NIOSH 2.15 (E) Spirometry Results Notification form edit Form Unchanged Repair queued
Form 0920-24IK Spirometry-Facility-Certification-Form Form Unchanged Available
Form CDC/NIOSH 2.14 (E) Spirometry Facility Certification Form Form Unchanged Available
Form 0920-24IK Respiratory Assessment Form Form Unchanged Available
Form CDC/NIOSH 2.13 (E) Respiratory Assessment Form Form Unchanged Available
Form 0920-24IK Chest Radiograph Classification Form Unchanged Available
Form CDC/NIOSH 2.8(E), Chest Radiograph Classification Form Unchanged Available
Form 0920-24IK Consent Release and History Form Form Unchanged Available
Form CDC/NIOSH 2.6 (02/ Consent, Release and History Form for Autopsy Form Unchanged Available
Form 0920-24IK Authorizaion for Payment of Autopsy Form Unchanged Available
Form CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Form Unchanged Available
Form 0920-24IK Authorizaion for Payment of Autopsy Form Unchanged Available
Form CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Form and Instruction Unchanged Available
Form 0920-24IK Consent Release and History Form for Autopsy Form and Instruction Unchanged Available
Form CDC/NIOSH 2.6 (02/ Consent, Release and History Form for Autopsy Form Unchanged Available
Form 0920-24IK Physician Certifcation Document Form Unchanged Available
Form CDC 2.12 (E), Rev Physician Application for Certification Form Unchanged Available
Form 0920-24IK Radiographic Facility Certification Form Form Unchanged Available
Form CDC 2.11 (E), rev Radiographic Facility Certification Form Unchanged Available
Form 0920-0020-24IK Operators Plan Form Unchanged Available
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan Form Unchanged Available
Form 0920-0020-24IK Miner Identification Form Unchanged Available
Form CDC/NIOSH 2.9(E), Miner Identification Document Form Unchanged Available
Change request justification 0920-0020 15JUL2025.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-07-15 Available
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 Available
Attachment 9_P01 Roster Letter to Miners.docx Supplementary Document Uploaded 2025-04-02 Available
Attachment 2_42 CFR Part 37 -- Specifications for Medical Examinations of Coal Miners.pdf Supplementary Document Uploaded 2025-04-02 Available
Attachment 1 Federal Mine Safety and Health Act of 1977.docx Supplementary Document Uploaded 2025-04-02 Available
Att 26_IRB Approval.docx Supplementary Document Uploaded 2022-02-04 Available
Att 25_OCISO Approval for the Collection of PII.docx Supplementary Document Uploaded 2022-02-04 Available
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 Available
Attachment 2b- 60day FRN.pdf Supplementary Document Uploaded 2022-02-04 Available
SSB_0920-0020_2025 ReInstmnt_FINAL.docx Supporting Statement B Uploaded 2025-04-02 Available
SSA_0920-0020_2025 ReINSTAMENT_4225.docx Supporting Statement A Uploaded 2025-04-02 Available
Attachment 2a.pdf Supplementary Document Uploaded 2021-12-02 Available
Attachment 1 Authorizing Authority.docx Supplementary Document Uploaded 2021-12-13 Available
IC Document Collections
IC IDCollectionTypeStatusForm
6620 Chest Radiograph Classification - B Reader Physician Form UnchangedChest Radiography
6620 Chest Radiograph Classification - B Reader Physician Form UnchangedChest Radiograph Classification
274684 B Reader for Physician Form UnchangedPhysicians reporting outcomes of B Reader Examinations
274683 Request for Medical Records Form ModifiedMedical Records Request Form - revised 15JUL2025
274683 Request for Medical Records Form ModifiedRequest for Medcial Record
250657 Pathologist Report Form UnchangedAuthorizaion for Payment of Autopsy
250657 Pathologist Report Form UnchangedAuthorization for Payment Autopsy
212093 Coal Contractor Plan CDC/NIOSH 2.18 Form UnchangedContractor Plan
212093 Coal Contractor Plan CDC/NIOSH 2.18 Form UnchangedCoal Contractor Plan
212090 Spirometry Results Notification Form Form UnchangedSpirometry Results
212090 Spirometry Results Notification Form Form UnchangedSpirometry Results Notification form edit
212089 Spirometry Facility Certification Form Form UnchangedSpirometry-Facility-Certification-Form
212089 Spirometry Facility Certification Form Form UnchangedSpirometry Facility Certification Form
212086 Respiratory Assessment Form - Spirometry Facility Employee Form UnchangedRespiratory Assessment Form
212086 Respiratory Assessment Form - Spirometry Facility Employee Form UnchangedRespiratory Assessment Form
197450 Coal Miner Radiograph (CWHSP) Form UnchangedChest Radiograph Classification
197450 Coal Miner Radiograph (CWHSP) Form UnchangedChest Radiograph Classification
197449 Spirometry Test for Coal Miners Form UnchangedConsent Release and History Form
197449 Spirometry Test for Coal Miners Form UnchangedConsent, Release and History Form for Autopsy
197448 Authorization for Payment of Autopsy Form UnchangedAuthorizaion for Payment of Autopsy
197448 Authorization for Payment of Autopsy Form UnchangedAuthorization for Payment of Autopsy
197447 Invoice-Pathologist Form UnchangedAuthorizaion for Payment of Autopsy
197447 Invoice-Pathologist Form and Instruction UnchangedAuthorization for Payment of Autopsy
197446 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form and Instruction UnchangedConsent Release and History Form for Autopsy
197446 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form UnchangedConsent, Release and History Form for Autopsy
183370 Physician Application for Certification (CDC/NIOSH 2.12) Form UnchangedPhysician Certifcation Document
183370 Physician Application for Certification (CDC/NIOSH 2.12) Form UnchangedPhysician Application for Certification
183369 Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form UnchangedRadiographic Facility Certification Form
183369 Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form UnchangedRadiographic Facility Certification
183368 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form UnchangedOperators Plan
183368 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form UnchangedCoal Mine Operator's Plan
183367 Miner Identification Document (CDC/NIOSH 2.9) Form UnchangedMiner Identification
183367 Miner Identification Document (CDC/NIOSH 2.9) Form UnchangedMiner Identification Document
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