Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Coal Miner Radiograph (CWHSP) Modified 4788 1197 0 Form CDC/NIOSH 2.8(E), Revised 01/2020 Chest Radiograph Classification
Form 0920-24IK Chest Radiograph Classification
Authorization for Payment of Autopsy Modified 4 1 0 Form CWHSP 2.19, Dec 2020 Authorization for Payment of Autopsy
Form 0920-24IK Authorizaion for Payment of Autopsy
B Reader for Physician New 1 18 0 Form 0920-24IK Physicians reporting outcomes of B Reader Examinations
Chest Radiograph Classification - B Reader Physician Modified 8990 450 0 Form CDC/NIOSH (M) 2.8 REV 01/2020 Chest Radiograph Classification
Form 0920-0020-24IK Chest Radiography
Coal Contractor Plan CDC/NIOSH 2.18 Modified 68 34 0 Form CDC/NIOSH (M) 2.18 (E), rev 01/2015 Coal Contractor Plan
Form 0920-24IK Contractor Plan
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Modified 268 134 0 Form CDC/NIOSH (M) 2.10 (E). rev 01/2015 Coal Mine Operator's Plan
Form 0920-0020-24IK Operators 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
Form and Instruction 0920-24IK Consent Release and History Form for Autopsy
Invoice-Pathologist Modified 4 1 0 Form and Instruction CWHSP 2.19, Dec 2020 Authorization for Payment of Autopsy
Form 0920-24IK Authorizaion for Payment of Autopsy
Miner Identification Document (CDC/NIOSH 2.9) Modified 4345 1448 0 Form CDC/NIOSH 2.9(E), Revised 02/2019 Miner Identification Document
Form 0920-0020-24IK Miner Identification
Pathologist Report Modified 4 1 0 Form CWHSP 2.19, 12/2020 Authorization for Payment Autopsy
Form 0920-24IK Authorizaion for Payment of Autopsy
Physician Application for Certification (CDC/NIOSH 2.12) Modified 4788 240 0 Form CDC 2.12 (E), Rev 02/2019 Physician Application for Certification
Form 0920-24IK Physician Certifcation Document
Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Modified 14 7 0 Form CDC 2.11 (E), rev 02/2015 Radiographic Facility Certification
Form 0920-24IK Radiographic Facility Certification Form
Request for Medical Records New 779 65 0 Form 0920-24IK Request for Medcial Record
Respiratory Assessment Form - Spirometry Facility Employee Modified 619 52 0 Form CDC/NIOSH 2.13 (E), rev 04/2016 Respiratory Assessment Form
Form 0920-24IK Respiratory Assessment Form
Spirometry Facility Certification Form Modified 15 8 0 Form CDC/NIOSH 2.14 (E), rev 06/2016 Spirometry Facility Certification Form
Form 0920-24IK Spirometry-Facility-Certification-Form
Spirometry Results Notification Form Modified 619 206 0 Form CDC/NIOSH 2.15 (E), rev 04/2015 Spirometry Results Notification form edit
Form 0920-24IK Spirometry Results
Spirometry Test for Coal Miners Modified 619 155 0 Form CDC/NIOSH 2.6 (02/2015) Consent, Release and History Form for Autopsy
Form 0920-24IK Consent Release and History Form
Total burden requested under this ICR: 25929 4018 0  
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