Information Collection

Radiation Sampling and Exposure Records

IC 14336 under ICR 202512-1219-002 · OMB 1219-0003.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form MSHA 4000-9 Record of Individual Exposure to Radon Daughters Radiation Sampling and Exposure Records	Form and Instruction
MSHA 4000-9.pdf www.msha.gov/support-resources/forms-online-filing/2018/05/23/record-individual-exposure-radon-daughters	Other-Print to View PDF of MSHA Form
MSHA 4000-9 Record of Individual Exposure to Radon Daughters MSHA_4000-9.pdf www.msha.gov/support-resources/forms-online-filing/2018/05/23/record-individual-exposure-radon-daughters	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 57.5037 30 CFR 57.5040

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Print to View PDF of MSHA Form 4000-9				https://www.msha.gov/support-resources/forms-online-filing/2018/05/23/record-individual-exposure-radon-daughters	Yes	Yes	Fillable Printable
Form and Instruction	MSHA 4000-9			https://www.msha.gov/support-resources/forms-online-filing/2018/05/23/record-individual-exposure-radon-daughters	Yes	Yes	Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: DOL-MSHA 1, Mine Safety and Health Administration Standardized Information System (MSIS)

FR Citation: 81 FR 25766

Number of Respondents: 4

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	404	404
Annual IC Time Burden (Hours)	402	402
Annual IC Cost Burden (Dollars)	20	20

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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