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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 718.202
20 CFR 725.406
20 CFR 718.204
20 CFR 718.102-105
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CM-933
Radiologic Interpretation
CM-933-Form Non-Sub.docx
https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black
Yes
Yes
Fillable Printable
Form
CM-933b
Radiologic Quality Rereading
CM-933b Non-Sub.docx
https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black
Yes
Yes
Fillable Printable
Form
CM-988
Medical History and Examination for Coal Mine Workers’ Pneumoconiosis
CM-988 Non-Sub.docx
https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black
Yes
Yes
Fillable Printable
Form
CM-1159
Report of Arterial Blood Gas Study
CM-1159 Non-Sub.docx
https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black
Yes
Yes
Fillable Printable
Form
CM-2907
Report of Ventilatory Study
CM-2907 Non-Sub.docx
https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
DOL/OWCP-2 and DOL/OWCP-9
FR Citation:
67 FR 16869
Number of Respondents:
21,500
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
50 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
21,500
0
0
0
0
21,500
Annual IC Time Burden (Hours)
5,232
0
0
0
0
5,232
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.