Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Coal Miner Radiograph (CWHSP) Modified 8500 2125 0 Form CDC/NIOSH 2.8(E), Revised 01/2020 Chest Radiograph Classification
Authorization for Payment of Autopsy Modified 4 1 0 Form CWHSP 2.19, Dec 2020 Authorization for Payment of Autopsy
Chest Radiograph Classification - B Reader Physician Modified 17600 880 0 Form CDC/NIOSH (M) 2.8 REV 01/2020 Chest Radiograph Classification
Coal Contractor Plan CDC/NIOSH 2.18 Modified 160 80 0 Form CDC/NIOSH (M) 2.18 (E), rev 01/2015 Coal Contractor Plan
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Modified 220 110 0 Form CDC/NIOSH (M) 2.10 (E). rev 01/2015 Coal Mine Operator's Plan
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Modified 4 1 0 Form CDC/NIOSH 2.6 (02/2015) Consent, Release and History Form for Autopsy
Invoice-Pathologist Modified 4 1 4 Form and Instruction CWHSP 2.19, Dec 2020 Authorization for Payment of Autopsy
Miner Identification Document (CDC/NIOSH 2.9) Modified 8500 2833 0 Form CDC/NIOSH 2.9(E), Revised 02/2019 Miner Identification Document
Pathologist Report New 4 1 4 Form CWHSP 2.19, 12/2020 Authorization for Payment Autopsy
Physician Application for Certification (CDC/NIOSH 2.12) Modified 220 37 0 Form CDC 2.12 (E), Rev 02/2019 Physician Application for Certification
Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Modified 20 10 0 Form CDC 2.11 (E), rev 02/2015 Radiographic Facility Certification
Respiratory Assessment Form - Spirometry Facility Employee Modified 8500 708 0 Form CDC/NIOSH 2.13 (E), rev 04/2016 Respiratory Assessment Form
Spirometry Facility Certification Form Modified 15 8 0 Form CDC/NIOSH 2.14 (E), rev 06/2016 Spirometry Facility Certification Form
Spirometry Results Notification Form Modified 8500 2833 0 Form CDC/NIOSH 2.15 (E), rev 04/2015 Spirometry Results Notification form edit
Spirometry Test for Coal Miners Modified 8500 2125 0 Form CDC/NIOSH 2.6 (02/2015) Consent, Release and History Form for Autopsy
Total burden requested under this ICR: 60751 11753 8  
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