Beltman Form

Postural Analysis in Low-Seam Mines

Attachment 3 - Beltman Form (2)

Beltman Form

OMB: 0920-0829

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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) ______

  1. Age (years) ___________

  2. Time in job (years) ___________

  3. Time in low height mines (years) ___________

  4. Type of knee pad used ___________

  5. Side SCSR is worn on ___________

  6. Side cap lamp battery is worn on ___________

  7. How control is worn ___________

  8. 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.__________________________________________

____________________________________________________________



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File Typeapplication/msword
File TitleStudy: Postural Analyses of Coal Mining in Low Working Heights: Effect of Working Height and Job Type
Authorjni3
Last Modified ByNelda Robinson
File Modified2009-06-30
File Created2009-05-29

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