Coal Workers' Health Surveillance Program (CWHSP)

Forms and Documents

Document Name	Status
Form CDC/NIOSH (M) 2.8 Roentgenographic Interpretation Form	Modified
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-X-ray Coal Miners Form	New
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test Form	New
Form 5 Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist Form	New
Form 5 Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist Form	New
Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) Form	New
Form CDC/NIOSH (M) 2.9 Interpretating Physician Certification Document Form and Instruction	Modified
Form CDC/NIOSH (M) 2.9 Facility Certification Document Form and Instruction	Modified
Form CDC/NIOSH (M) 2.9 Coal Mine Operator's Plan Form and Instruction	Modified
Form CDC/NIOSH (M) 2.9 Miner Identification Document Form and Instruction	Modified
SuppStmt B 04.14.11.docx Supporting Statement B	2011-04-25
Attmt 13- 4.18.11.docx Supplementary Document	2011-04-26
Attmt 3- 42 CFR Part 37 4.14.11.doc Supplementary Document	2011-04-25
SuppStat A_ 04 26 14 (2).doc Supporting Statement A	2011-04-26

IC Document Collections

IC ID	Document Title	Status
6620	Roentgenographic Interpretation Form	Modified
197450	Coal Workers' Health Surveillance Program (CWHSP)-X-ray Coal Miners Form	New
197449	Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test Form	New
197448	Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist Form	New
197447	Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist Form	New
197446	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) Form	New
183370	Interpretating Physician Certification Document Form and Instruction	Modified
183369	Facility Certification Document Form and Instruction	Modified
183368	Coal Mine Operator's Plan Form and Instruction	Modified
183367	Miner Identification Document Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0020	ICR Reference No: 201104-0920-016
Status: Historical Active	Previous ICR Reference No: 200801-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Coal Workers' Health Surveillance Program (CWHSP)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/04/2011
	Date Received in OIRA: 04/26/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2014	36 Months From Approved	06/30/2011
Responses	23,250	0	15,525
Time Burden (Hours)	4,471	0	2,330
Cost Burden (Dollars)	0	0	0

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Abstract: This submission will incorporate the National Coal Workers' X-Ray Surveillance Program 42 CFR 37 (0920-0020) and National Coal Workers' Autopsy Study 42 CFR Part 37.204 (0920-0021) into one complete package which will be called the Coal Workers' Health Surveillance Program (CWHSP).

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Authorizing Statute(s): PL: Pub.L. 95 - 164 111 Name of Law: Federal Mine Safety & Health Act of 1977, Public Law 91-173, as amended by Public Law 95-164
   PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 10369	02/24/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 22902	04/25/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

IC Title	Form No.	Form Name
Facility Certification Document	CDC/NIOSH (M) 2.9, CDC/NIOSH (M) 2.10, CDC/NIOSH (M) 2.11, 4	Miner Identification Document ,   Coal Mine Operator's Plan ,   Facility Certification Document ,   Facility Certification Document
Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)	5	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6)
Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist	5, 6	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) ,   Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist
Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist	5, 6, 9	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) ,   Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist ,   Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Coal Workers' Health Surveillance Program (CWHSP)-Spirometry Test	5, 6, 9	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) ,   Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist ,   Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Coal Workers' Health Surveillance Program (CWHSP)-X-ray Coal Miners	5, 6, 9	Coal Workers' Health Surveillance Program (CWHSP)-Consent Release and History Form- Next of Kim (form 2.6) ,   Coal Workers' Health Surveillance Program (CWHSP)- Invoice-Pathologist ,   Coal Workers' Health Surveillance Program (CWHSP)- Report Pathologist
Roentgenographic Interpretation	CDC/NIOSH (M) 2.8	Roentgenographic Interpretation
Miner Identification Document	CDC/NIOSH (M) 2.9	Miner Identification Document
Interpretating Physician Certification Document	CDC/NIOSH (M) 2.9, CDC/NIOSH (M) 2.10, CDC/NIOSH (M) 2.11, CDC/NIOSH (M) 2.12	Miner Identification Document ,   Coal Mine Operator's Plan ,   Facility Certification Document ,   Facility Certification Document
Coal Mine Operator's Plan	CDC/NIOSH (M) 2.9, CDC/NIOSH (M) 2.10	Miner Identification Document ,   Coal Mine Operator's Plan

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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	23,250	15,525	0	0	7,725	0
Annual Time Burden (Hours)	4,471	2,330	0	0	2,141	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We are requesting an increase of 2141 burden hours for this approval period due to the increase in the number of participating miners, and an increase in the number of applications from newly eligible digital x-ray facilities. This increase also reflects the increase related to the combining of the two OMB submissions (0920-0020 and 0920-0021) into one comprehensive CWHSP packet.

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Annual Cost to Federal Government: $1,146,488

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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Common Form ICR:  No

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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: 04/26/2011

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