Information Collection

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

IC 13765 under ICR 201703-1240-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Radiologic Interpretation (CM-933), Radiologic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of.... Form
CM-933b Radiologic Quality Rereading CM-933b.pdf www.dol.gov/owcp/regs/compliance/cm-933b.pdf Form
CM-933 Radiologic Interpretation CM-933.pdf www.dol.gov/owcp/regscompliance/cm-933.pdf Form
CM-1159 Report of Arterial Blood Gas Test CM-1159.pdf www.dol.gov/owcp/reg/compliance/cm-1159.pdf Form
CM-2907 Report of Ventilatory Study CM-2907.pdf www.dol.gov/owcp/regs/compliance/cm-2907.pdf Form
CM-988 Medical History and Examination CM-988 and CM-988a.pdf www.dol.gov/owcp/regs/compliance/cm-988.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Radiologic Interpretation (CM-933), Radiologic 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	CM-933b.pdf	http://www.dol.gov/owcp/regs/compliance/cm-933b.pdf	Yes	No	Fillable Printable
Form	CM-933	Radiologic Interpretation	CM-933.pdf	http://www.dol.gov/owcp/regscompliance/cm-933.pdf	Yes	No	Fillable Printable
Form	CM-1159	Report of Arterial Blood Gas Test	CM-1159.pdf	http://www.dol.gov/owcp/reg/compliance/cm-1159.pdf	Yes	No	Fillable Printable
Form	CM-2907	Report of Ventilatory Study	CM-2907.pdf	http://www.dol.gov/owcp/regs/compliance/cm-2907.pdf	Yes	No	Fillable Printable
Form	CM-988	Medical History and Examination	CM-988 and CM-988a.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: 27,500	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	27,500	3,500	24,000
Annual IC Time Burden (Hours)	6,693	853	5,840
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.