Facility Certification Document

National Coal Workers' X-ray Surveillance Program (CWXSP) - Federal Mine Safety and Health Act 1977 (42CFR37)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0020 can be found here:

Documents and Forms

Document Name Document Type
Form CDC/NIOSH (M) 2.9 Facility Certification Document Form and Instruction
CDC/NIOSH (M) 2.9 Miner Identification Document Form 2.9.pdf Form and Instruction
CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan Form 210.pdf Form and Instruction
CDC/NIOSH (M) 2.11 Facility Certification Document Form 211.pdf Form and Instruction
4 Facility Certification Document Attmt 7- CWHSP-Facility-2.11v2010.pdf Form

Information Collection (IC) Details

IC Title:	Facility Certification Document	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CDC/NIOSH (M) 2.9	Miner Identification Document	Form 2.9.pdf	No	No	Paper Only
Form and Instruction	CDC/NIOSH (M) 2.10	Coal Mine Operator's Plan	Form 210.pdf	No	No	Paper Only
Form and Instruction	CDC/NIOSH (M) 2.11	Facility Certification Document	Form 211.pdf	No	No	Paper Only
Form	4	Facility Certification Document	Attmt 7- CWHSP-Facility-2.11v2010.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 0920-0149-Mortality Studies in Coal Mining, Metal and Non-Metal Mining and General Industry and 0920-0153- Mortality Studies in coal Mining, Metal and Non-Metal Mining and General Industry.	FR Citation: 72 FR 42414

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.