Beltman Form

Postural Analyses of Coal Mining in Low Working Heights:

Effect of Working Height and Job Type

1. Subject Code ___________

2. Date ___________

3. Time ___________

4. Height (feet +inches) ___________ (meters) ______

5. Weight (lbs) ___________ (kilograms) ______

Body Mass Index (kg/m²) ______

6. Age (years) ___________

7. Time in job (years) ___________

8. Time in low height mines (years) ___________

9. Type of knee pad used ___________

10. Side SCSR is worn on ___________

11. Side cap lamp battery is worn on ___________

12. How control is worn ___________

13. Weight of mining belt (lbs) ___________ (kilograms) ______

Items worn on mining belt: ­­­­­­­­­­­­­­­_________________________________________________

________________________________________________________________________

Least physically demanding task that you perform on a daily basis: _________________

________________________________________________________________________

Most physically demanding task that you perform on a daily basis: __________________ ________________________________________________________________________

Comments on knee pads used. _______________________________________________

________________________________________________________________________________________________________________________________________________

How often do you clean your knee pads? ______________________________________

How do you clean them? ___________________________________________________

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintain the data needed, and completing 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Subjects will be asked the following questions by a NIOSH representative. This data will be used to determine whether or not an injury to the knee may have influenced the postures utilized by the subject.

Check all that apply:

____ Diagnosed knee injury:_________________________

____ Pain/Redness/Swelling in front of knee

____ Infection/ Hardening at the front of knee

____ Popping feeling in knee

____ Pain inside the knee

____ Catching/Locking of knee

____ Instability/Feeling like knee is going to give away

____ Knee stiffness after waking up

____ General knee weakness

Please check all tasks that you perform on a daily basis.

____ Building stoppings

____ Rock dusting

____ Scooping/clean up

____ Bolting where unfinished

____ Advancing power load center

____ Moving/advancing belt (where applicable)

____ Changing miner bits

____ Other (please explain) _____________________________________

________________________________________________________

Task:_____________________________________________

How many hours do you spend performing this task on a daily basis? ____

Which two postures from the above chart (1-16) do you use most often?

1. _____ b)_____

What percentage of your time is spent in each posture (a, b)?

1. _____ % b) _____ %

Did the subject indicate that they used an obscure posture (posture not on list)?

If so, please describe.__________________________________________

____________________________________________________________

Task:_____________________________________________

How many hours do you spend performing this task on a daily basis? ____

Which two postures from the above chart (1-16) do you use most often?

1. _____ b)_____

What percentage of your time is spent in each posture (a, b)?

1. _____ % b) _____ %

Did the subject indicate that they used an obscure posture (posture not on list)?

If so, please describe.__________________________________________

____________________________________________________________

Task:_____________________________________________

How many hours do you spend performing this task on a daily basis? ____

Which two postures from the above chart (1-16) do you use most often?

1. _____ b)_____

What percentage of your time is spent in each posture (a, b)?

1. _____ % b) _____ %

Did the subject indicate that they used an obscure posture (posture not on list)?

If so, please describe.__________________________________________

____________________________________________________________

Task:_____________________________________________

How many hours do you spend performing this task on a daily basis? ____

Which two postures from the above chart (1-16) do you use most often?

1. _____ b)_____

What percentage of your time is spent in each posture (a, b)?

1. _____ % b) _____ %

Did the subject indicate that they used an obscure posture (posture not on list)?

If so, please describe.__________________________________________

____________________________________________________________

Task:_____________________________________________

How many hours do you spend performing this task on a daily basis? ____

Which two postures from the above chart (1-16) do you use most often?

1. _____ b)_____

What percentage of your time is spent in each posture (a, b)?

1. _____ % b) _____ %

Did the subject indicate that they used an obscure posture (posture not on list)?

If so, please describe.__________________________________________

____________________________________________________________

Task:_____________________________________________

How many hours do you spend performing this task on a daily basis? ____

Which two postures from the above chart (1-16) do you use most often?

1. _____ b)_____

What percentage of your time is spent in each posture (a, b)?

1. _____ % b) _____ %

Did the subject indicate that they used an obscure posture (posture not on list)?

If so, please describe.__________________________________________

____________________________________________________________

Task:_____________________________________________

How many hours do you spend performing this task on a daily basis? ____

Which two postures from the above chart (1-16) do you use most often?

1. _____ b)_____

What percentage of your time is spent in each posture (a, b)?

1. _____ % b) _____ %

Did the subject indicate that they used an obscure posture (posture not on list)?

If so, please describe.__________________________________________

____________________________________________________________

Task:_____________________________________________

How many hours do you spend performing this task on a daily basis? ____

Which two postures from the above chart (1-16) do you use most often?

1. _____ b)_____

What percentage of your time is spent in each posture (a, b)?

1. _____ % b) _____ %

Did the subject indicate that they used an obscure posture (posture not on list)?

If so, please describe.__________________________________________

____________________________________________________________

Task:_____________________________________________

How many hours do you spend performing this task on a daily basis? ____

Which two postures from the above chart (1-16) do you use most often?

1. _____ b)_____

What percentage of your time is spent in each posture (a, b)?

1. _____ % b) _____ %

Did the subject indicate that they used an obscure posture (posture not on list)?

If so, please describe.__________________________________________

____________________________________________________________

7