CDC/NIOSH (M) 2.10 Coal Mine Operator's Plan

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Form Approved OMB No.: 0920-0020
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOR NIOSH USE ONLY
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
COAL MINE OPERATOR'S PLAN
Name of Company Officer in Charge of Program

NIOSH

RETURN COAL WORKERS' HEALTH SURVEILLANCE PROGRAM
PO Box 4258
TO
MORGANTOWN, WEST VIRGINIA 26504

1.
Title
2.
Telephone Number

Name of Mine Operator

4.

3.
Street Address

City

State

5.

6.

7.

Mine Name

Mine Identification Number

Zip Code
8.
Number Miners

9.
Mine Mailing Address (Box Number, Street)

City

State

Zip Code

11.
County

12.

13.

14.

15.

16.

10.

Name(s) of X-Ray Facility(ies)

Certification Number

Number Miles from Mine

17.

18.

19.

Name(s) of Interpreting Physician(s)

Physician's Address

20.

21.

Time Schedule

Begin Date

End Date

Days

Hours

6 mos+

22.

23.

24.

25.

Remarks (If given at mine, include number of change houses and location and name of change houses where mobile facility will set up.)

26.
I am participating in this program in the manner specified by Part 37 of the Title 42 of the Code of Federal Regulations (42 CFR Part
37) and understand that all information used in connection with this program will be held STRICTLY CONFIDENTIAL and divulged only
as specified by the above regulations. I hereby assure that (1) the X-Ray findings or findings of any medical test of any miner examined
under this plan will not be solicited from the Physician or Facility providing the examination; (2) I have advised the Physician and Facility
providing the examinations under this plan that duplicate X-Rays or test results are not to be taken or made and no information that
would identify the miner shall be recorded on the film or test results except as provided in the above Regulation; and (3) all examination
made under this plan will be at no cost to the miner.
Signature of Mine Operator or Legal Representative

Date
27.

CDC/NIOSH (M) 2.10 Rev. 07/2007

**SEE REVERSE SIDE FOR INSTRUCTIONS**

Public reporting burden of this collection of this information is estimate to average 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600
Clifton Road, MS D-24, Atlanta, GA, 30333 ATTN:PRA (0920-0020). Do not send the completed form to this address.

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Instructions for Completion of
Coal Mine Operator Plan
Form N. CDC/NIOSH(M)2.10
1

Name of Company Officer In Charge of Program - Name of Individual to be contacted relative to
implementation of plan.

2

Title - Title of individual listed in block #1.

3

Name of Mine Operator - Name of Mine Operator or parent company .

4

Telephone Number - Telephone number for contact purposes for information relative to coal mine operator
plan (individual noted in block # 1)

5.thru 8

Address of mine operator or parent company

9

Name of Mine - Specific name of mine (not company)

10

Mine Identification Number - Identification Number assigned by MSHA

11I

Number Miners - Approximate number of miners employed or to be employed

12. thru 15

Mine Mailing Address - Mine address, not company address (address where approved plan will be sent.)

16

County - Name of county where mine is located

17

Name(s) of X-ray Facility(ies) - Facility(ies) where examinations are to be conducted. If mobile facility is
to be used, a local facility should also be named to conduct pre-employment and mandatory examinations,

19

Certification Number - NIOSH Certification Number (can be located in facility list)

19

Number Miles from Mine - Distance from facility to mine

20. thru 21

Name and Address of Interpreting Physician - Name and address of physician(s) who will read films for the
facility where films are made (this information can be obtained from the facility)

TIME SCHEDULE
22

Begin date - Beginning date of period during which miners will have an opportunity for x-rays. If mine is
new, program should begin within one month of the date you submit your plan. If mine is not yet in
operation, program should begin when hiring starts to allow for pre-employment x-rays. If a mobile facility
is to be used, the begin date should indicate the first date that the mobile unit will be at the mine. Enter
date (month, day, year) when examinations will begin.

23

End Date - End date of 6-rnonth period during which miners will have opportunity for x-rays. Program
should end six months after beginning date. If a mobile facility is to be used, the end date should indicate
the last date that the mobile unit will be at the mine. Enter date (month, day, year) when examinations will
stop (voluntary examinations only).

24

Days - Days of week when miners may be examined (i.e., Mon-Fri)

25

Hours - Hours during each day when miners may be examined at facility (i.e., 8-0-0 a.m. thru 4-00 p.m.). If
mobile unit is to be used hours are usually one hour before and one hour after shift change.

26

Remarks - Other pertinent information. Indicate which facility will conduct mandatory and /or repeat xrays. If using mobile facility indicate the number of change houses, location and name of change houses
where facility will be set up. Indicate if miners may be examined at facility on a walk-in basis, or if
appointment will be required, whether or not miners work rotating shifts, and if appointments will be made
at miners convenience or will miners be released from work.

27

Signature (must be original, not stamp or copy) and date plan is submitted.