National Coal Workers' Health Surveillance Program (CWHSP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
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	Available
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	Available
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

Information collection document groups

IC ID	Collection	Type	Status	Form
6620	Chest Radiograph Classification - B Reader Physician	Form	Unchanged	Chest Radiography
6620	Chest Radiograph Classification - B Reader Physician	Form	Unchanged	Chest Radiograph Classification
274684	B Reader for Physician	Form	Unchanged	Physicians reporting outcomes of B Reader Examinations
274683	Request for Medical Records	Form	Modified	Medical Records Request Form - revised 15JUL2025
274683	Request for Medical Records	Form	Modified	Request for Medcial Record
250657	Pathologist Report	Form	Unchanged	Authorizaion for Payment of Autopsy
250657	Pathologist Report	Form	Unchanged	Authorization for Payment Autopsy
212093	Coal Contractor Plan CDC/NIOSH 2.18	Form	Unchanged	Contractor Plan
212093	Coal Contractor Plan CDC/NIOSH 2.18	Form	Unchanged	Coal Contractor Plan
212090	Spirometry Results Notification Form	Form	Unchanged	Spirometry Results
212090	Spirometry Results Notification Form	Form	Unchanged	Spirometry Results Notification form edit
212089	Spirometry Facility Certification Form	Form	Unchanged	Spirometry-Facility-Certification-Form
212089	Spirometry Facility Certification Form	Form	Unchanged	Spirometry Facility Certification Form
212086	Respiratory Assessment Form - Spirometry Facility Employee	Form	Unchanged	Respiratory Assessment Form
212086	Respiratory Assessment Form - Spirometry Facility Employee	Form	Unchanged	Respiratory Assessment Form
197450	Coal Miner Radiograph (CWHSP)	Form	Unchanged	Chest Radiograph Classification
197450	Coal Miner Radiograph (CWHSP)	Form	Unchanged	Chest Radiograph Classification
197449	Spirometry Test for Coal Miners	Form	Unchanged	Consent Release and History Form
197449	Spirometry Test for Coal Miners	Form	Unchanged	Consent, Release and History Form for Autopsy
197448	Authorization for Payment of Autopsy	Form	Unchanged	Authorizaion for Payment of Autopsy
197448	Authorization for Payment of Autopsy	Form	Unchanged	Authorization for Payment of Autopsy
197447	Invoice-Pathologist	Form	Unchanged	Authorizaion for Payment of Autopsy
197447	Invoice-Pathologist	Form and Instruction	Unchanged	Authorization for Payment of Autopsy
197446	Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)	Form and Instruction	Unchanged	Consent Release and History Form for Autopsy
197446	Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)	Form	Unchanged	Consent, Release and History Form for Autopsy
183370	Physician Application for Certification (CDC/NIOSH 2.12)	Form	Unchanged	Physician Certifcation Document
183370	Physician Application for Certification (CDC/NIOSH 2.12)	Form	Unchanged	Physician Application for Certification
183369	Radiographic Facility Certification (CDC/NIOSH (M) 2.11)	Form	Unchanged	Radiographic Facility Certification Form
183369	Radiographic Facility Certification (CDC/NIOSH (M) 2.11)	Form	Unchanged	Radiographic Facility Certification
183368	Coal Mine Operator's Plan (CDC/NOISH (M) 2.10)	Form	Unchanged	Operators Plan
183368	Coal Mine Operator's Plan (CDC/NOISH (M) 2.10)	Form	Unchanged	Coal Mine Operator's Plan
183367	Miner Identification Document (CDC/NIOSH 2.9)	Form	Unchanged	Miner Identification
183367	Miner Identification Document (CDC/NIOSH 2.9)	Form	Unchanged	Miner Identification Document

ICR Details

OMB Control No: 0920-0020	ICR Reference No: 202507-0920-012
Status: Active	Previous ICR Reference No: 202501-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0020-24IK
Title: National Coal Workers' Health Surveillance Program (CWHSP)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/17/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/17/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2028	06/30/2028	06/30/2028
Responses	25,929	0	25,929
Time Burden (Hours)	4,018	0	4,018
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 71273	09/30/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 14452	04/01/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 17

table that charts list of burden

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

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ICR Summary of Burden

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	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,699,239

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/17/2025

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