CM-911A Employment History

U.S. Department of Labor

Employment History
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Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

Note: Persons are not required to respond to this collection of information unless it displays currently valid OMB
control number.

OMB No. 1215-0052
Expires: 08-31-08

Please complete as accurately as possible the miner's complete employment history. (Where employment was in
coal mining, specify whether the mine was a strip mine or an underground mine.) This report is authorized by law (30
U.S.C. 901 et. seq.) and required to obtain a benefit. While you are not required to respond, your cooperation is needed
to ensure that full and proper consideration is given to this claim. Disclosure of the social security number is voluntary.
Failure to disclose such number will not result in the denial of any right, privilege or benefit to which you may be entitled.
Miner's Name
First Name

Miner's Social Security Number

M.I.

Last Name
2.

1.

Name and Address of Employer
(City and State)

4.

3.

Type of Industry
(Indicate if coal mining, extraction
or preparation of coal, coal mine
construction, or transportation in
or around a coal mine, steel,
manufacturing or other)

Occupation
(Specify type
of work)

5.

Period of
Employment

Mo/Yr

Mo/Yr

Exposure to dust,
gases, or fumes?

(Yes/No)

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Form CM-911a
Rev. March 2003

1.

Name and Address of Employer
(City and State)

2.

Type of Industry
(indicate if coal mining, extraction
or preparation of coal, coal mine
construction, or transportation in
or around a coal mine, steel,
manufacturing or other)

3.

Occupation
(Specify type
of work)

4.

Period of
Employment

Mo/Yr

Mo/Yr

5.

Exposure to dust,
gases, or fumes?

(Yes/No)

Yes

No

Yes

No

Yes

No

Yes

No

I hereby certify that the Information given by me on and In connection with this form Is true and correct to the best of my
knowledge and belief. I am also fully aware that any person who willfully makes any false or misleading statement or
representation for the purpose of obtaining any benefit or payment under this title shall be guilty of a misdemeanor and on
conviction thereof shall be punished by a fine of not more than $1,000, or by Imprisonment for not more than one year or both.
7. Date (Month, date, year)
6. Signature of Claimant (First, middle, last)

8. Mailing Address (Number, Street, Apt. No., P.O. Box or Rural Route)

9. City and State

10. ZIP Code

12. Telephone number (include area code)

11. County where you live

Witnesses are required only if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to
the signing who know the applicant must sign below, giving their full address.
Signature of Witness

Signature of Witness

Address (Number, Street, City, State & ZIP Code)

Address (Number, Street, City, State & ZIP Code)

city:
state:

city:
state:

zip:

zip:

PRIVACY ACT STATEMENT
The following statement is made in accordance with the Privacy Act of 1974, as amended (5 U.S.C 552a). (1) Submission of this report
is required under the Black Lung Benefits Act. (2) The information in the report will be used to determine eligibility under the Act. (3) The
information may be used by other agencies or persons in handling matters relating, directly or indirectly, to the subject matter of the claim,
so long as such agencies or persons have received the consent of the individual claimant or beneficiary, or have complied with the provisions
of 20 CFR Part 725. (4) Furnishing all requested information will facilitate the claims adjudication process; and the effects of not providing
all or any part of the requested information may delay the process, or result in an unfavorable decision or a reduced level of benefits.
(Disclosure of your social security number is voluntary; the failure to disclose such number will not result in the denial of any right, benefit
or privilege to which an individual may be entitled.)
Public Burden Statement
Public reporting burden for this collection of information is estimated to average 40 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U.S. Department of Labor, Division of Coal Mine Workers' Compensation, Room N-3464, 200 Constitution Avenue,
N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE