OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

National Coal Workers' Health Surveillance Program (CWHSP)

OMB 0920-0020 ยท HHS/CDC.

OMB 0920-0020

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.

The latest form for National Coal Workers' Health Surveillance Program (CWHSP) expires 2028-06-30 and is listed under ICR 202507-0920-012.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 0920-0020-24IK Chest RadiographyForm
Form CDC/NIOSH (M) 2.8 Chest Radiograph ClassificationForm
Form 0920-24IK Physicians reporting outcomes of B Reader ExaminationsForm
Form 0920-0020 Medical Records Request Form - revised 15JUL2025Form
Form 0920-24IK Request for Medcial RecordForm
Form 0920-24IK Authorizaion for Payment of AutopsyForm
Form CWHSP 2.19, 12/202 Authorization for Payment AutopsyForm
Form 0920-24IK Contractor PlanForm
Form CDC/NIOSH (M) 2.18 Coal Contractor PlanForm
Form 0920-24IK Spirometry ResultsForm
Form CDC/NIOSH 2.15 (E) Spirometry Results Notification form editForm
Form 0920-24IK Spirometry-Facility-Certification-FormForm
Form CDC/NIOSH 2.14 (E) Spirometry Facility Certification FormForm
Form 0920-24IK Respiratory Assessment FormForm
Form CDC/NIOSH 2.13 (E) Respiratory Assessment FormForm
Form 0920-24IK Chest Radiograph ClassificationForm
Form CDC/NIOSH 2.8(E), Chest Radiograph ClassificationForm
Form 0920-24IK Consent Release and History FormForm
Form CDC/NIOSH 2.6 (02/ Consent, Release and History Form for AutopsyForm
Form 0920-24IK Authorizaion for Payment of AutopsyForm
Form CWHSP 2.19, Dec 20 Authorization for Payment of AutopsyForm
Form 0920-24IK Authorizaion for Payment of AutopsyForm
Form CWHSP 2.19, Dec 20 Authorization for Payment of AutopsyForm and Instruction
Form 0920-24IK Consent Release and History Form for AutopsyForm and Instruction
Form CDC/NIOSH 2.6 (02/ Consent, Release and History Form for AutopsyForm
Form 0920-24IK Physician Certifcation DocumentForm
Form CDC 2.12 (E), Rev Physician Application for CertificationForm
Form 0920-24IK Radiographic Facility Certification FormForm
Form CDC 2.11 (E), rev Radiographic Facility CertificationForm
Form 0920-0020-24IK Operators PlanForm
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's PlanForm
Form 0920-0020-24IK Miner IdentificationForm
Form CDC/NIOSH 2.9(E), Miner Identification DocumentForm
Change request justification 0920-0020 15JUL2025.docxJustification for No Material/Nonsubstantive Change
Attachment 24 OCISO Standard Limiting use of SSN in CDC Infor Syst.docxSupplementary Document
Attachment 26 IRB Approval.docxSupplementary Document
Attachment 9_P01 Roster Letter to Miners.docxSupplementary Document
Attachment 2_42 CFR Part 37 -- Specifications for Medical Examinations of Coal Miners.pdfSupplementary Document
Attachment 1 Federal Mine Safety and Health Act of 1977.docxSupplementary Document
Att 26_IRB Approval.docxSupplementary Document
Att 25_OCISO Approval for the Collection of PII.docxSupplementary Document
Att 24_OCISO Standard Limiting use of SSN in CDC Infor Syst.docxSupplementary Document
Att 23_Contact Information for Stakeholders.docxSupplementary Document
Attachment 2b- 60day FRN.pdfSupplementary Document
SSB_0920-0020_2025 ReInstmnt_FINAL.docxSupporting Statement B
SSA_0920-0020_2025 ReINSTAMENT_4225.docxSupporting Statement A
Attachment 2a.pdfSupplementary Document
Attachment 1 Authorizing Authority.docxSupplementary Document
Chest Radiograph Classification - B Reader Physician Form
Chest Radiograph Classification - B Reader Physician Form
B Reader for Physician Form
Request for Medical Records Form
Request for Medical Records Form
Pathologist Report Form
Pathologist Report Form
Coal Contractor Plan CDC/NIOSH 2.18 Form
Coal Contractor Plan CDC/NIOSH 2.18 Form
Spirometry Results Notification Form Form
Spirometry Results Notification Form Form
Spirometry Facility Certification Form Form
Spirometry Facility Certification Form Form
Respiratory Assessment Form - Spirometry Facility Employee Form
Respiratory Assessment Form - Spirometry Facility Employee Form
Coal Miner Radiograph (CWHSP) Form
Coal Miner Radiograph (CWHSP) Form
Spirometry Test for Coal Miners Form
Spirometry Test for Coal Miners Form
Authorization for Payment of Autopsy Form
Authorization for Payment of Autopsy Form
Invoice-Pathologist Form
Invoice-Pathologist Form and Instruction
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) 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
Physician Application for Certification (CDC/NIOSH 2.12) Form
Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form
Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form
Miner Identification Document (CDC/NIOSH 2.9) Form
Miner Identification Document (CDC/NIOSH 2.9) Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202507-0920-012 No material or nonsubstantive change to a currently approved collection 2025-07-17 Approved without change
202501-0920-010 Reinstatement with change of a previously approved collection 2025-05-02
202111-0920-021 Revision of a currently approved collection 2022-02-07 Approved without change
202109-0920-001 Extension without change of a currently approved collection 2021-09-09 Approved without change
202105-0920-011 Revision of a currently approved collection 2021-05-25 Improperly submitted and continue
202104-0920-005 No material or nonsubstantive change to a currently approved collection 2021-04-22 Approved without change
201903-0920-009 No material or nonsubstantive change to a currently approved collection 2019-04-17 Approved without change
201806-0920-008 Extension without change of a currently approved collection 2018-06-28 Approved without change
201604-0920-005 No material or nonsubstantive change to a currently approved collection 2016-04-13 Approved without change
201503-0920-003 Reinstatement without change of a previously approved collection 2015-03-23 Approved without change
201406-0920-018 Revision of a currently approved collection 2014-07-09 Approved with change
201403-0920-010 Revision of a currently approved collection 2014-03-20 Approved without change
201306-0920-003 No material or nonsubstantive change to a currently approved collection 2013-06-10 Approved without change
201302-0920-006 No material or nonsubstantive change to a currently approved collection 2013-02-08 Approved without change
201104-0920-016 Revision of a currently approved collection 2011-04-26 Approved without change
200801-0920-006 Reinstatement with change of a previously approved collection 2008-01-11 Approved without change
200404-0920-006 Extension without change of a currently approved collection 2004-04-08 Approved without change
200104-0920-001 Extension without change of a currently approved collection 2001-04-02 Approved without change
199802-0920-001 Extension without change of a currently approved collection 1998-02-23 Approved without change
199501-0920-002 Reinstatement without change of a previously approved collection 1995-01-27 Approved without change
199104-0920-003 Revision of a currently approved collection 1991-04-17 Approved without change
198802-0920-001 Extension without change of a currently approved collection 1988-02-05 Approved without change
198503-0920-002 Reinstatement with change of a previously approved collection 1985-03-04 Approved without change
198107-0920-005 No material or nonsubstantive change to a currently approved collection 1981-07-17 Approved with change
197907-0920-001 Revision of a currently approved collection 1979-07-27 Approved without change
197510-0920-002 Reinstatement with change of a previously approved collection 1975-10-16 Approved without change

OMB Details

Chest Radiograph Classification - B Reader Physician

Federal Enterprise Architecture: Health - Illness Prevention

Information collection instruments
FormNameElectronic accessType
Form CDC/NIOSH (M) 2.8 REV 01/2020Chest Radiograph ClassificationFillable FileableForm
Form 0920-0020-24IKChest RadiographyFillable FileableForm

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