Information Collection

Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....

IC 13765 under ICR 201412-1240-015 · OMB 1240-0023.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0023 can be found here:

Documents and Forms

Document Name Document Type
Form CM-933b Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form
CM-933b Radiologic Quality Rereading 2014 CM-933b Final.pdf www.dol.gov/owcp/regs/compliance/cm-933b.pdf Form
CM-933 Radiologic Interpretation 2014 CM-933 Final.pdf www.dol.gov/owcp/regscompliance/cm-933.pdf Form
CM-1159 Report of Arterial Blood Gas Test 2014 cm-1159 Final.pdf www.dol.gov/owcp/reg/compliance/cm-1159.pdf Form
CM-2907 Report of Ventilatory Study 2014 CM-2907 Final.pdf www.dol.gov/owcp/regs/compliance/cm-2907.pdf Form
CM-988 Medical History and Examination 2014 cm-988 Final.pdf www.dol.gov/owcp/regs/compliance/cm-988.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 718.102-105

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-933b	Radiologic Quality Rereading	2014 CM-933b Final.pdf	http://www.dol.gov/owcp/regs/compliance/cm-933b.pdf	Yes	No	Fillable Printable
Form	CM-933	Radiologic Interpretation	2014 CM-933 Final.pdf	http://www.dol.gov/owcp/regscompliance/cm-933.pdf	Yes	No	Fillable Printable
Form	CM-1159	Report of Arterial Blood Gas Test	2014 cm-1159 Final.pdf	http://www.dol.gov/owcp/reg/compliance/cm-1159.pdf	Yes	No	Fillable Printable
Form	CM-2907	Report of Ventilatory Study	2014 CM-2907 Final.pdf	http://www.dol.gov/owcp/regs/compliance/cm-2907.pdf	Yes	No	Fillable Printable
Form	CM-988	Medical History and Examination	2014 cm-988 Final.pdf	http://www.dol.gov/owcp/regs/compliance/cm-988.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ESA-6, DOL/ESA-30	FR Citation: 67 FR 16869

Number of Respondents: 24,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	24,000	24,000
Annual IC Time Burden (Hours)	5,840	5,840
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.