National Coal Workers' Health Surveillance Program (CWHSP)

Forms and Documents

Document Name	Status
Form CDC/NIOSH (M) 2.8 Chest Radiograph Classification - B Reader Physician Form	Unchanged
Form 0920-24IK B Reader for Physician Form	Unchanged
Form 0920-24IK Request for Medical Records Form	Modified
Form CWHSP 2.19, 12/202 Pathologist Report Form	Unchanged
Form CDC/NIOSH (M) 2.18 Coal Contractor Plan CDC/NIOSH 2.18 Form	Unchanged
Form CDC/NIOSH 2.15 (E) Spirometry Results Notification Form Form	Unchanged
Form CDC/NIOSH 2.14 (E) Spirometry Facility Certification Form Form	Unchanged
Form CDC/NIOSH 2.13 (E) Respiratory Assessment Form - Spirometry Facility Employee Form	Unchanged
Form CDC/NIOSH 2.8(E), Coal Miner Radiograph (CWHSP) Form	Unchanged
Form CDC/NIOSH 2.6 (02/ Spirometry Test for Coal Miners Form	Unchanged
Form CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy Form	Unchanged
Form CWHSP 2.19, Dec 20 Invoice-Pathologist Form and Instruction	Unchanged
Form CDC/NIOSH 2.6 (02/ Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form	Unchanged
Form CDC 2.12 (E), Rev Physician Application for Certification (CDC/NIOSH 2.12) Form	Unchanged
Form CDC 2.11 (E), rev Radiographic Facility Certification (CDC/NIOSH (M) 2.11) Form	Unchanged
Form CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan (CDC/NOISH (M) 2.10) Form	Unchanged
Form CDC/NIOSH 2.9(E), Miner Identification Document (CDC/NIOSH 2.9) Form	Unchanged
Change request justification 0920-0020 15JUL2025.docx Justification for No Material/Nonsubstantive Change	2025-07-15
Attachment 24 OCISO Standard Limiting use of SSN in CDC Infor Syst.docx Supplementary Document	2025-04-02
Attachment 26 IRB Approval.docx Supplementary Document	2025-04-02
Attachment 9_P01 Roster Letter to Miners.docx Supplementary Document	2025-04-02
Attachment 2_42 CFR Part 37 -- Specifications for Medical Examinations of Coal Miners.pdf Supplementary Document	2025-04-02
Attachment 1 Federal Mine Safety and Health Act of 1977.docx Supplementary Document	2025-04-02
Att 26_IRB Approval.docx Supplementary Document	2022-02-04
Att 25_OCISO Approval for the Collection of PII.docx Supplementary Document	2022-02-04
Att 24_OCISO Standard Limiting use of SSN in CDC Infor Syst.docx Supplementary Document	2022-02-04
Att 23_Contact Information for Stakeholders.docx Supplementary Document	2022-02-04
Attachment 2b- 60day FRN.pdf Supplementary Document	2022-02-04
SSB_0920-0020_2025 ReInstmnt_FINAL.docx Supporting Statement B	2025-04-02
SSA_0920-0020_2025 ReINSTAMENT_4225.docx Supporting Statement A	2025-04-02
Attachment 2a.pdf Supplementary Document	2021-12-02
Attachment 1 Authorizing Authority.docx Supplementary Document	2021-12-13

IC Document Collections

IC ID	Document Title	Status
6620	Chest Radiograph Classification - B Reader Physician Form	Unchanged
274684	B Reader for Physician Form	Unchanged
274683	Request for Medical Records Form	Modified
250657	Pathologist Report Form	Unchanged
212093	Coal Contractor Plan CDC/NIOSH 2.18 Form	Unchanged
212090	Spirometry Results Notification Form Form	Unchanged
212089	Spirometry Facility Certification Form Form	Unchanged
212086	Respiratory Assessment Form - Spirometry Facility Employee Form	Unchanged
197450	Coal Miner Radiograph (CWHSP) Form	Unchanged
197449	Spirometry Test for Coal Miners Form	Unchanged
197448	Authorization for Payment of Autopsy Form	Unchanged
197447	Invoice-Pathologist Form and 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	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: 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
	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

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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.

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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

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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:
	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

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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

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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	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:

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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

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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: 07/17/2025

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