National Coal Workers' Health Surveillance Program (CWHSP)

OMB 0920-0020

The Coal Workers' Health Surveillance Program (CWHSP) is a congressionally-mandated medical examination program for monitoring the health of underground coal miners, established under the Federal Coal Mine Health and Safety Act of 1969. Through delegation of authority, the Act directs NIOSH to study the causes and consequences of coal-related respiratory disease, and in cooperation with the Mine Safety and Health Administration, to carry out a program for early detection and prevention of coal workers' pneumoconiosis and to provide the opportunity for an autopsy after the death of a coal miner. An extension is being requested with only a few minor changes (costs). This Non-Substantive Change Request is submitted to make minor changes to the following forms/procedures: Chest Radiograph Classification Form Miner Identification Document Physician Application for Certification Recertification period for B Readers Changes result in an overall decrease in four Burden Hours.

The latest form for National Coal Workers' Health Surveillance Program (CWHSP) expires 2021-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CDC/NIOSH (M) 2.8 Chest Radiograph Classification - B Reader Physician Form
Form CWHSP 2.19, 12/202 Pathologist Report Form
Form CDC/NIOSH (M) 2.18 Coal Contractor Plan CDC/NIOSH 2.18 Form
Form CDC/NIOSH 2.15 (E) Spirometry Results Notification Form Form
Form CDC/NIOSH 2.14 (E) Spirometry Facility Certification Form Form
Form CDC/NIOSH 2.13 (E) Respiratory Assessment Form - Spirometry Facility Employee Form
Form CDC/NIOSH 2.8(E), Coal Miner Radiograph (CWHSP) Form
Form CDC/NIOSH 2.6 (02/ Spirometry Test for Coal Miners Form
Form CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Form
Form CWHSP 2.19, Dec 20 Invoice-Pathologist Form and Instruction
Form CDC/NIOSH 2.6 (02/ Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form
Form CDC 2.12 (E), Rev Physician Application for Certification (CDC/NIOSH 2.12) Form
Form CDC 2.11 (E), rev Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form
Form CDC/NIOSH 2.9(E), Miner Identification Document (CDC/NIOSH 2.9) Form
Att 26_IRB Approval.docx Supplementary Document
Att 25_OCISO Approval for the Collection of PII.docx Supplementary Document
Att 24_OCISO Standard Limiting use of SSN in CDC Infor Syst.docx Supplementary Document
Att 23_Contact Information for Stakeholders.docx Supplementary Document
Attachment 2b- 60day FRN.pdf Supplementary Document
SSB_11.15.21.docx Supporting Statement B
SSA_12.17.21.docm Supporting Statement A
Attachment 2a.pdf Supplementary Document
Attachment 1 Authorizing Authority.docx Supplementary Document
Chest Radiograph Classification - B Reader Physician Form
Pathologist Report Form
Coal Contractor Plan CDC/NIOSH 2.18 Form
Spirometry Results Notification Form Form
Spirometry Facility Certification Form Form
Respiratory Assessment Form - Spirometry Facility Employee Form
Coal Miner Radiograph (CWHSP) Form
Spirometry Test for Coal Miners Form
Authorization for Payment of Autopsy Form
Invoice-Pathologist Form and Instruction
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form
Physician Application for Certification (CDC/NIOSH 2.12) Form
Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form
Miner Identification Document (CDC/NIOSH 2.9) Form

All Historical Document Collections

202111-0920-021 Approved without change	Revision of a currently approved collection	2022-02-07
202109-0920-001 Approved without change	Extension without change of a currently approved collection	2021-09-09
202105-0920-011 Improperly submitted and continue	Revision of a currently approved collection	2021-05-25
202104-0920-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2021-04-22
201903-0920-009 Approved without change	No material or nonsubstantive change to a currently approved collection	2019-04-17
201806-0920-008 Approved without change	Extension without change of a currently approved collection	2018-06-28
201604-0920-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-04-13
201503-0920-003 Approved without change	Reinstatement without change of a previously approved collection	2015-03-23
201406-0920-018 Approved with change	Revision of a currently approved collection	2014-07-09
201403-0920-010 Approved without change	Revision of a currently approved collection	2014-03-20
201306-0920-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2013-06-10
201302-0920-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2013-02-08
201104-0920-016 Approved without change	Revision of a currently approved collection	2011-04-26
200801-0920-006 Approved without change	Reinstatement with change of a previously approved collection	2008-01-11
200404-0920-006 Approved without change	Extension without change of a currently approved collection	2004-04-08
200104-0920-001 Approved without change	Extension without change of a currently approved collection	2001-04-02
199802-0920-001 Approved without change	Extension without change of a currently approved collection	1998-02-23
199501-0920-002 Approved without change	Reinstatement without change of a previously approved collection	1995-01-27
199104-0920-003 Approved without change	Revision of a currently approved collection	1991-04-17
198802-0920-001 Approved without change	Extension without change of a currently approved collection	1988-02-05
198503-0920-002 Approved without change	Reinstatement with change of a previously approved collection	1985-03-04
198107-0920-005 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-07-17
197907-0920-001 Approved without change	Revision of a currently approved collection	1979-07-27
197510-0920-002 Approved without change	Reinstatement with change of a previously approved collection	1975-10-16

OMB Details

Chest Radiograph Classification (CDC/NIOSH Form 2.8)

Federal Enterprise Architecture: Health - Illness Prevention

Form 2.8	Chest Radiograph Classification	Fillable Fileable	Form
Form 0920-0020	Chest Radiograph Classification Form M 2.8 25MAR2019	NA	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.