Form 2.10 Coal Operator's Plan

Form Approved
OMB No.: 9020-0020
Exp. Date xx/xx/xxxx
1. MSHA Mine Identification Number
DEPARTMENT OF HEALTH AND HUMAN SERVICES
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
COAL MINE OPERATOR'S PLAN
2. Name of Company Officer in Charge of Program

NIOSH
RETURN COAL WORKERS’ HEALTH SURVEILLANCE PROGRAM
TO
1095 Willowdale Road M/S LB208
Morgantown, WV 26505

3. Title of Officer in Charge

4. Name of Mine Operator/Company

5. Telephone Number

6. Street Address

7. City

8. State

11. County

10. Mine Name

13. Mine Mailing Address (Box number, Street)

14. City

9. Zip Code

12. Number Miners

15. State

Time Schedule 6 months plus

17. Begin Date

18. End Date.

To be completed by NIOSH

19. Approved Date

20. Plan Expiration date

21. Mine Type

22. Mine Status

16. Zip Code

23. Remarks (If given at mine, include number of change houses and location and name of change houses where mobile facility will set up.)

I am participating in this program in the manner specified by Part 37 of the Title 42 of the Code of Federal Regulations (42 CFR
Part 37) and understand that all information used in connection with this program will be held STRICTLY CONFIDENTIAL and
Divulged only as specified by the above regulations. I hereby assure that (1) the X-Ray findings or findings of any medical test of
any miner examined under this plan will not be solicited from the Physician or Facility providing the examination; (2) I have advised
the Physician and Facility providing the examinations under this plan that duplicate X-Rays or test results are not to be taken or
made and no information that would identify the miner shall be recorded on the film or test results except as provided in the above
Regulation; and (3) all examination made under this plan will be at no cost to the miner.
24. Date

Signature of Mine Operator or Legal Representative

25. Date

Signature of NIOSH Approver (NIOSH ONLY)

Complete the reverse side of form indicating each Facility Identification.
CDC/NIOSH (M) 2.10 Rev. 06/2014
Public reporting burden of this collection of this information is estimate to average 30 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, Project Clearance Officer, 1600
Clifton Road, MS D-24, Atlanta, GA, 30333 ATTN: PRA (0920-0020). Do not send the completed form to this address.

26. Name(s) of X-Ray Facility(ies)

27. Certification
Number

28. # Miles
from Mine

29. Days

30. Hours

31. Name(s) of Spirometry Facility(ies)

32. Certification
Number

33. # Miles
from Mine

34. Days

35. Hours