National Coal Workers' Health Surveillance Program (CWHSP)

Forms and Documents

Document Name	Status
Form 2.8 Chest Radiograph Classification (CDC/NIOSH Form 2.8) Form	Unchanged
Form 2.18 Coal Contractor Plan CDC/NIOSH 2.18 Form	Unchanged
Form 2.15 Spirometry Results Notification CDC/NIOSH 2.15 Form	Unchanged
Form 2.14 Spirometry Facility Supervisor - Certification Document 2.14 Form	Unchanged
Form 2.13 Spirometry Facility Employee - Respiratory Assessment 2.13 Form	Unchanged
Form 2.6 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form	Unchanged
Form 2.12 Physician Application for Certification (CDC/NIOSH 2.12) Form and Instruction	Unchanged
Form 2.11 Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form	Unchanged
Form 2.10 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form	Unchanged
Form 2.9 Miner Identification Document (CDC/NIOSH 2.9) Form	Unchanged
Emergency Request Memo CWHSP.docx Supplementary Document	2021-09-08
Request for Nonsubstantive Changes OMB #0920-0020_2021MAR17.docx Justification for No Material/Nonsubstantive Change	2021-04-22
Request for Nonsubstantive Change 2019.docx Justification for No Material/Nonsubstantive Change	2019-03-26
Attachment 27 Public Comments .docx Supplementary Document	2018-06-25
Attachment 25 OCISO PII.docx Supplementary Document	2018-06-25
Attachment 24 OCISO SSN.docx Supplementary Document	2018-06-25
Attachment 18 Sample Letter Spiro Results.docx Supplementary Document	2018-06-25
Attachment 14 Sample Letter B Reader Due to Recertify.docx Supplementary Document	2018-06-25
Attachment 13 Sample Letters B Reader Exam Results.docx Supplementary Document	2018-06-25
Attachment 10 Sample Letter Results.docx Supplementary Document	2018-06-25
Attachment 9 Sample Letter Participation.docx Supplementary Document	2018-06-25
Attachment 7 Sample Letter Rad Fac Approval.docx Supplementary Document	2018-06-25
Attachment 5 Sample Letters.docx Supplementary Document	2018-06-25
Attachment 2 42 CFR Part 37.docx Supplementary Document	2018-06-20
Attachment 23 Stakeholder Information.docx Supplementary Document	2018-06-20
Attachment 26 IRB Determination.docx Supplementary Document	2018-06-20
60 day FRN.pdf Supplementary Document	2018-06-19
Attachment 2.docx Supplementary Document	2015-03-18
SupSta B_0920-0020 CWHSP 03 05 2018.docx Supporting Statement B	2018-06-19
SupSta A_0920-0020_ICRO edits formatting.docx Supporting Statement A	2018-06-28
Attachment 1- revised.docx Supplementary Document	2014-07-30
Att 1_Medical Exam excerpt.docx Supplementary Document	2014-03-07

IC Document Collections

IC ID	Document Title	Status
6620	Chest Radiograph Classification (CDC/NIOSH Form 2.8) Form	Unchanged
212093	Coal Contractor Plan CDC/NIOSH 2.18 Form	Unchanged
212090	Spirometry Results Notification CDC/NIOSH 2.15 Form	Unchanged
212089	Spirometry Facility Supervisor - Certification Document 2.14 Form	Unchanged
212086	Spirometry Facility Employee - Respiratory Assessment 2.13 Form	Unchanged
197450	Coal Miner Radiograph (CWHSP) Instruction	Unchanged
197449	Spirometry Test for Coal Miners Instruction	Unchanged
197448	Report - Pathologist Instruction	Unchanged
197447	Invoice-Pathologist Instruction	Unchanged
197446	Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form	Unchanged
183370	Physician Application for Certification (CDC/NIOSH 2.12) Form and Instruction	Unchanged
183369	Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form	Unchanged
183368	Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form	Unchanged
183367	Miner Identification Document (CDC/NIOSH 2.9) Form	Unchanged

ICR Details

OMB Control No: 0920-0020	ICR Reference No: 202109-0920-001
Status: Received in OIRA	Previous ICR Reference No: 202104-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0020
Title: National Coal Workers' Health Surveillance Program (CWHSP)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 09/29/2021
Date Submitted to OIRA: 09/09/2021

	Requested	Previously Approved
Expiration Date	6 Months From Approved	09/30/2021
Responses	104,126	104,126
Time Burden (Hours)	20,274	20,274
Cost Burden (Dollars)	0	0

---

Abstract: The Coal Workers' Health Surveillance Program (CWHSP) is a congressionally-mandated medical examination program for monitoring the health of underground coal miners, established under the Federal Coal Mine Health and Safety Act of 1969. Through delegation of authority, the Act directs NIOSH to study the causes and consequences of coal-related respiratory disease, and in cooperation with the Mine Safety and Health Administration, to carry out a program for early detection and prevention of coal workers' pneumoconiosis and to provide the opportunity for an autopsy after the death of a coal miner.

Emergency Justfication: CDC requests an Emergency Extension of 0920-0020 -National Coal Workers' Health Surveillance Program (CWHSP). As the collection is associated with a mandated/required Program,the standard clearance processing time will prevent the CDC/NIOSH from being in compliance with the statue. CDC requests approval for this Emergency Extension in order to prevent a lapse in collection activities.

---

Authorizing Statute(s): US Code: 42 USC 37 Name of Law: Specifications for Medical Exam of Coal Miners
   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
  

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

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 14

IC Title	Form No.	Form Name
Coal Miner Radiograph (CWHSP)
Chest Radiograph Classification (CDC/NIOSH Form 2.8)	0920-0020, 2.8	Chest Radiograph Classification ,   Chest Radiograph Classification Form M 2.8 25MAR2019
Coal Contractor Plan CDC/NIOSH 2.18	2.18	Coal Contractor Plan
Coal Mine Operator's Plan (CDC/NOISH (M) 2.10)	2.10	Coal Mine Operator's Plan
Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)	2.6	Consent, Release and History Form for Autopsy
Invoice-Pathologist
Miner Identification Document (CDC/NIOSH 2.9)	0920-0020, 2.9, 2.9	Miner Identification Document ,   Miner Identificaiton Document ,   Miner Identification Document Form M 2.9 25MAR2019
Physician Application for Certification (CDC/NIOSH 2.12)	2.12	Physician Application for Certification
Radiographic Facility Certification (CDC/NIOSH (M) 2.11)	2.11	Radiographic Facility Certification
Report - Pathologist
Spirometry Facility Employee - Respiratory Assessment 2.13	2.13	Respiratory Assessment
Spirometry Facility Supervisor - Certification Document 2.14	2.14	Spirometry Facility Certification
Spirometry Results Notification CDC/NIOSH 2.15	2.15	Spirometry Results Notification form edit
Spirometry Test for Coal Miners

---

ICR Summary of Burden

	Total Request	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	104,126	104,126	0	0	0	0
Annual Time Burden (Hours)	20,274	20,274	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: $2,499,239

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.     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

---

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: 09/09/2021

---