View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0920-0020
ICR Reference No:
202507-0920-012
Status:
Active
Previous ICR Reference No:
202501-0920-010
Agency/Subagency:
HHS/CDC
Agency Tracking No:
0920-0020-24IK
Title:
National Coal Workers' Health Surveillance Program (CWHSP)
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
07/17/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/17/2025
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2028
06/30/2028
06/30/2028
Responses
25,929
0
25,929
Time Burden (Hours)
4,018
0
4,018
Cost Burden (Dollars)
0
0
0
Abstract:
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.
Authorizing Statute(s):
PL:
Pub.L. 91 - 173 203
Name of Law: Federal Coal Mine Health and Safety Act
PL:
Pub.L. 91 - 596 20
Name of Law: Occupational Safety and Health Act
US Code:
42 USC 37
Name of Law: Specifications for Medical Exam of Coal Miners
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
89 FR 71273
09/30/2024
30-day Notice:
Federal Register Citation:
Citation Date:
90 FR 14452
04/01/2025
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
17
IC Title
Form No.
Form Name
Coal Miner Radiograph (CWHSP)
CDC/NIOSH 2.8(E), Revised 01/2020, 0920-24IK
Chest Radiograph Classification
,
Chest Radiograph Classification
Authorization for Payment of Autopsy
CWHSP 2.19, Dec 2020, 0920-24IK
Authorization for Payment of Autopsy
,
Authorizaion for Payment of Autopsy
B Reader for Physician
0920-24IK
Physicians reporting outcomes of B Reader Examinations
Chest Radiograph Classification - B Reader Physician
CDC/NIOSH (M) 2.8 REV 01/2020, 0920-0020-24IK
Chest Radiograph Classification
,
Chest Radiography
Coal Contractor Plan CDC/NIOSH 2.18
CDC/NIOSH (M) 2.18 (E), rev 01/2015, 0920-24IK
Coal Contractor Plan
,
Contractor Plan
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10)
CDC/NIOSH (M) 2.10 (E). rev 01/2015, 0920-0020-24IK
Coal Mine Operator's Plan
,
Operators Plan
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)
CDC/NIOSH 2.6 (02/2015), 0920-24IK
Consent, Release and History Form for Autopsy
,
Consent Release and History Form for Autopsy
Invoice-Pathologist
CWHSP 2.19, Dec 2020, 0920-24IK
Authorization for Payment of Autopsy
,
Authorizaion for Payment of Autopsy
Miner Identification Document (CDC/NIOSH 2.9)
CDC/NIOSH 2.9(E), Revised 02/2019, 0920-0020-24IK
Miner Identification Document
,
Miner Identification
Pathologist Report
CWHSP 2.19, 12/2020, 0920-24IK
Authorization for Payment Autopsy
,
Authorizaion for Payment of Autopsy
Physician Application for Certification (CDC/NIOSH 2.12)
CDC 2.12 (E), Rev 02/2019, 0920-24IK
Physician Application for Certification
,
Physician Certifcation Document
Radiographic Facility Certification (CDC/NIOSH (M) 2.11)
CDC 2.11 (E), rev 02/2015, 0920-24IK
Radiographic Facility Certification
,
Radiographic Facility Certification Form
Request for Medical Records
0920-24IK, 0920-0020
Request for Medcial Record
,
Medical Records Request Form - revised 15JUL2025
Respiratory Assessment Form - Spirometry Facility Employee
CDC/NIOSH 2.13 (E), rev 04/2016, 0920-24IK
Respiratory Assessment Form
,
Respiratory Assessment Form
Spirometry Facility Certification Form
CDC/NIOSH 2.14 (E), rev 06/2016, 0920-24IK
Spirometry Facility Certification Form
,
Spirometry-Facility-Certification-Form
Spirometry Results Notification Form
CDC/NIOSH 2.15 (E), rev 04/2015, 0920-24IK
Spirometry Results Notification form edit
,
Spirometry Results
Spirometry Test for Coal Miners
CDC/NIOSH 2.6 (02/2015), 0920-24IK
Consent, Release and History Form for Autopsy
,
Consent Release and History Form
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
25,929
25,929
0
0
0
0
Annual Time Burden (Hours)
4,018
4,018
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$2,699,239
Does this IC contain surveys, censuses, or employ statistical methods?
Yes
Part B of Supporting Statement
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
No
Agency Contact:
Jeffrey Zirger 404 639-7118 wtj5@cdc.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
07/17/2025
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