Information Collection

Radiation Sampling and Exposure Records

IC 14336 under ICR 202002-1219-005 · OMB 1219-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0003 can be found here:

Documents and Forms

Document Name Document Type
Form 4000-9 Radiation Sampling and Exposure Records Form and Instruction
4000-9 Record of Individual Exposure to Radon Daughters MSHA Form 4000-9 (Record of Individual Exposure to Radon Daughters).pdf www.msha.gov/sites/default/files/Support_Resources/Forms/4000-9.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Radiation Sampling and Exposure Records	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 57.5040 30 CFR 57.5037

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4000-9	Record of Individual Exposure to Radon Daughters	MSHA Form 4000-9 (Record of Individual Exposure to Radon Daughters).pdf	https://www.msha.gov/sites/default/files/Support_Resources/Forms/4000-9.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: DOL-MSHA 1, Mine Safety and Health Administration Standardized Information System (MSIS)	FR Citation: 81 FR 25766

Number of Respondents: 4	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 40 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	404	-101	505
Annual IC Time Burden (Hours)	402	-100	502
Annual IC Cost Burden (Dollars)	20	-5	25

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.