Information Collection

Radiation Sampling and Exposure Records

IC 14336 under ICR 202502-1219-002 · OMB 1219-0003.

Documents and Forms

Document Name Document Type
Form MSHA 4000-9 Radiation Sampling and Exposure Records Form and Instruction
MSHA 4000-9 Record of Individual Exposure to Radon Daughters MSHA_4000-9.pdf www.msha.gov/sites/default/files/Support_Resources/Forms/4000-9_3.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 57.5037 30 CFR 57.5040

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	MSHA 4000-9	Record of Individual Exposure to Radon Daughters	MSHA_4000-9.pdf	https://www.msha.gov/sites/default/files/Support_Resources/Forms/4000-9_3.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: 95 %

	Approved	Previously Approved
Annual Number of Responses for this IC	404	404
Annual IC Time Burden (Hours)	402	402
Annual IC Cost Burden (Dollars)	20	20

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.