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OMB Control No: 1219-0152	ICR Reference No: 202512-1219-004
Status: Received in OIRA	Previous ICR Reference No: 202303-1219-006
Agency/Subagency: DOL/MSHA	Agency Tracking No: 10/31/26 Exp
Title: Periodic Medical Surveillance Examinations for Coal Miners
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 08/26/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2026
Responses	761	797
Time Burden (Hours)	296	310
Cost Burden (Dollars)	228	239

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	761	797	-36
Annual Time Burden (Hours)	296	310	-14
Annual Cost Burden (Dollars)	228	239	-11

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: Number of Respondents: The estimated number of respondents decreases from 664 to 634 due to a decrease in the number of coal mines. Number of Responses: The estimated number of responses decreases from 797 to 761 due to a decrease in the number of respondents (coal mines). Annual Time Burden: The estimated annual time burden decreases from 310 to 296 hours due to a decrease in the number of responses. Annual Recordkeeping Costs: The estimated annual recordkeeping costs decreases from $239 to $228 due to a decrease in the number of responses.

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

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. No

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. No

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: Joanna Moore 202 693-9825 moore.joanna@dol.gov

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