Form 5 Coal Workers' Health Surveillance Program (CWHSP)-Consen

ATTACHMENT 9

Consent, Release and History Form No. CDC/NIOSH (M) 2.6

Form Approved

OMB No. 0920-0021

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

National Coal Workers= Autopsy Study

Consent, Release and History Form

Federal Coal Mine Health and Safety Act of 1969

I, ____________________________________, ____________________________________ of

Name Relationship

________________________________________, do hereby authorize the performance of an

Name of deceased miner

autopsy (________________________________) on said deceased. I understand that the report

Limitation, if any, on autopsy

and certain tissues as necessary will be released to the United States Public Health Service and

to ____________________________________________. I understand that any claims in regard

Name of physician securing autopsy

to the deceased for which I may sign a general release of medical information will result in the release of the information from the Public Health Service. I further understand that I shall not make any payment for the autopsy.

OCCUPATIONAL AND MEDICAL HISTORY

1. Date of Birth of Deceased ___________________________

Month Day Year

2. Social Security Number of Deceased __________________________

3. Date and Place of Death _____________________________________________

Month, Day, Year City, County, State

4. Place of Last Mining Employment:

Name of Mine _______________________

Name of Mining Company _______________________

Mine Address _______________________

5. Date of Last Work or Retirement ___________________

6. Last Job Title at Mine of Last Employment ________________________________________

(specify surface or underground) e.g., Continuous Miner Operator, Motorman, Foreman, etc.

7. Job Title of Principal Mining Occupation (that job to which miner devoted the most number of years): (specify surface or underground) ____________________________________

e.g., same as above

8. Smoking History of Miner:

(a) Did he ever smoke cigarettes? Yes  No 

(b) If yes, for how many years? ______Years

(c) If yes, how many cigarettes per day

did he smoke on the average? ______ Number of cigarettes per day

(d) Did he smoke cigarettes up until the

time of his death? Yes  No 

(e) If no to (d), for how long before he died had he not been smoking cigarettes? __________

9. Total Years in Surface Employment in Coal Mining, by State (if known) _______ _______________

(Years) (State)

10. Total Years in Underground Coal Mining Employment, by State (if known) _______ _______________

(Years) (State)

_______________________________

Signature

_________________________

Street

_________________________

City State Zip

_________________________

Telephone

Interviewer: _________________________

Date

____________________

CDC/NIOSH 2.6 (11-74)

(Formerly OSH-1 [2-71])

Public reporting burden of this collection of information is estimated to average 15 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: Paperwork Reduction Project (0920-0021)