Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)

National Coal Workers' Health Surveillance Program (CWHSP)

⚠️ Notice: This information collection may be referencing outdated material.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 2.6 Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6) Form
2.6 Consent, Release and History Form for Autopsy Attachment 19.doc Form

Information Collection (IC) Details

IC Title:	Consent Release and History Form- Next of Kin (CDC/NIOSH 2.6)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2.6	Consent, Release and History Form for Autopsy	Attachment 19.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-20-0153 Mortality Studies in Coal Mining	FR Citation: 51 FR 4247

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1	-4	5
Annual IC Time Burden (Hours)	0	-1	1
Annual IC Cost Burden (Dollars)	0	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.