Form CDC/NIOSH (M) 2.9 CDC/NIOSH (M) 2.9 Miner Identification Document

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MINER IDENTIFICATION DOCUMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICES
UNITED STATES PUBLIC HEALTH SERVICE
CENTERS FOR DISEASE CONTROL AND PREVENTION
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
COAL WORKERS' HEALTH SURVEILLANCE PROGRAM (CWHSP)
DIRECTIONS FOR X-RAY FACILITY:
PLEASE MAKE SURE THAT ALL ITEMS ARE
COMPLETED. THEN RETURN FORM AND X-RAY
TO: NIOSH
COAL WORKERS' HEALTH SURVEILLANCE
PROGRAM
PO BOX 4258
MORGANTOWN, WV 26504-4258

FOR NIOSH USE ONLY
Analog

Digital
Spirometry

X-RAY FACILITY: NAME

CERTIFICATION NO.

TYPE OF X-RAY
NIOSH CWHSP

OTHER
Please Specify

DATE OF X-RAY (MM/DD/YYYY)

/

/

MINER'S SOCIAL SECURITY NUMBER

DIRECTIONS FOR THE MINER
PLEASE COMPLETE AND MAKE ANY CORRECTIONS TO
THE INFORMATION BELOW. (PLEASE PRINT)
MINER'S NAME (LAST)

OMB No.: 0920-0020

-

(FIRST)

SEX

(MI)

M

BIRTH DATE (MM/DD/YYYY)

/
MINER'S MAILING ADDRESS

CITY

STATE

MINER'S TELEPHONE NUMBER

(

)

/
ZIP

RACE (check all that apply)

-

F

ETHNICITY

American Indian or Alaska Native

Hispanic or Latino

Asian

Not Hispanic or Latino

Black or African American

MINE NAME

Native Hawaiian or Other Pacific Islander
White

Is your employer a

Mine Operator

Contractor

MSHA Mine ID Number

EMPLOYER'S NAME

If contractor, enter
MSHA Contractor Number
STREET

CITY

When Did You First Start Work
in the Coal Mine Industry?

Started
Underground
Underground

/

Year

Month

Year

Surface
Years

How Many Total Years You Have
Worked Underground at the Face?

ZIP

Started
Surface

/
Month

How Many Total Years You Have
Worked in the Coal Mine Industry?

STATE

Years

How Many Total Years You Have
Worked at Your Current Coal Mine?
Years

Years

Do you wear a respirator (including dust masks) at work (exclude self-rescuers)?

No

Yes

If Yes, what type? (Mark all that apply)
Dust mask (disposable)

Half - face mask (other than disposable)

Full - face

Hood / Helmet

I wish to participate in the Coal Workers' Health Surveillance Program conducted under Section 203 of the Federal Mine Safety and Health Act of 1977 (30 U.S.C 843).
I understand that a report of my X-ray will be mailed to me and my health information will be confidential unless otherwise compelled by law.

Signature
CDC/NIOSH (M) 2.9
REV. 7/07

Date Signed
(MM / DD / YYYY)

/

/

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Coal Mining Job History

COAL MINER JOB

MINE NAME/COMPANY

YEARS

Please List in Order Any Coal Mine Job You Have Held and Mine Name.
(If information is provided please correct and/or update.).

UNDERGROUND

Start year:

End year:

Face

1985

1990

X

Nonface

SURFACE
COAL
Surface
MINE

Example:
Continuous Miner Operator

Mine Name/Company

Have You Ever Worked in Any Mine Other than Coal?

metal mines
(For example, lead,
copper, gold, silver)

Surface

years worked

Underground

years worked

No

Yes

If Yes, please record number of years worked:

nonmetal mines
(For example, salt,
phosphate, limestone)

Have You Ever Worked for More than 1 Year in Any Other Dusty Job?

No

Yes

Surface

years worked

Underground

years worked

If Yes, please record number of years:

Work with asbestos, vermiculite, or talc

years

In foundry, pottery, or abrasive manufacturing

years

Tunneling, drilling, quarrying, sand blasting

years

Welding, cutting, or grinding metals

years

Road construction, jack hammer, masonry saw

years

Other dusty job (please specify)

years

Public reporting burden of this collection of information is estimated to average 20 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 the burden to CDC, Project
Clearance Officer, 1600 Clinton Road, MS E-11, Atlanta, GA 30333, ATTN: PRA (0920-0020). Do not send the completed form to this address.

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