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Form CDC 2.12 (E), Rev CDC 2.12 (E), Rev Physician Application for Certification
National Coal Workers' Health Surveillance Program (CWHSP)
Attachment 12 Physician Application for Cert Form No. CDC NIOSH (M) 2.12
Physician Application for Certification (CDC/NIOSH 2.12)
OMB: 0920-0020
OMB.report
HHS/CDC
OMB 0920-0020
ICR 202111-0920-021
IC 183370
Form CDC 2.12 (E), Rev CDC 2.12 (E), Rev Physician Application for Certification
( )
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0020 can be found here:
2025-07-17 - No material or nonsubstantive change to a currently approved collection
2025-05-02 - Reinstatement with change of a previously approved collection
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