Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Coal Mine Operator's Plan Modified 200 100 0 Form and Instruction CDC/NIOSH (M) 2.9 Miner Identification Document
Form and Instruction CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan
Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist New 50 4 0 Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
Form 6 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist New 50 4 0 Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
Form 6 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
Form and Instruction 9 Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) New 50 13 0 Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test New 2500 833 0 Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
Form 6 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
Form and Instruction 9 Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Coal Workers' Health Surveillance Program (CWHSP)-X-ray Coal Miners New 5000 1250 0 Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
Form 6 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
Form and Instruction 9 Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Facility Certification Document Modified 100 50 0 Form and Instruction CDC/NIOSH (M) 2.9 Miner Identification Document
Form and Instruction CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan
Form and Instruction CDC/NIOSH (M) 2.11 Facility Certification Document
Form 4 Facility Certification Document
Interpretating Physician Certification Document Modified 300 50 0 Form and Instruction CDC/NIOSH (M) 2.9 Miner Identification Document
Form and Instruction CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan
Form and Instruction CDC/NIOSH (M) 2.11 Facility Certification Document
Form and Instruction CDC/NIOSH (M) 2.12 Facility Certification Document
Miner Identification Document Modified 5000 1667 0 Form and Instruction CDC/NIOSH (M) 2.9 Miner Identification Document
Roentgenographic Interpretation Modified 10000 500 0 Form CDC/NIOSH (M) 2.8 Roentgenographic Interpretation
Total burden requested under this ICR: 23250 4471 0  
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