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Date _______________________________
ICR 201509-0920-003 · OMB 0920-0981 · Object 58648301.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Date _______________________________ |
| Author | CDC User:bme |
| Last Modified By | Writer |
| File Modified | 2013-05-01 |
| File Created | 2026-10-30 |
| Conversion State | complete |
Extracted Text
Appendix H: Safety Director Questionnaire
Form Approved
OMB No. 0920-xxxx
Expires xx/xx/20xx
Date _______________________________ ID# ______________
Safety Director Questionnaire
We would like if you could complete a questionnaire about the specific machinery and equipment you use at the mine where you work. This questionnaire includes three (3) sections. You will be given specific instructions for each of the sections. Please make sure to read the instructions before answering the questions. We ask that you complete each section with as complete and as accurate information as possible. If you do not use a piece of equipment or machinery at the mine where you work, you can indicate that in your response with a Not Applicable (N/A) response. Please try to complete as much of the questionnaire as possible.
Section 1
In this section, you are asked to provide general information about the miner where you work. Please provide as complete and as accurate information as possible.
Mine Information
1. What is the average seam height of your mine?
2. How many active sections are you currently running?
3. How many production continuous mining machines do you operate on a typical day in each active section?
Public reporting burden of this collection of information is estimated to average 30 minutes or less 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-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
4. How many production shifts do you typically run per day?
5. How many production days do you typically run per week?
Section 2
For this section, you are asked to provide information about the equipment you use at the mine where you work. Please provide as complete and as accurate information as possible. If you use more than one make and model, please include that information for all questions.
Equipment Used
6. What is the make and model of the continuous mining machine that you currently use?
______________________________________________________________________________
7. How many years have you been using that continuous mining machine? _______
8. Do you use 3rd party or Original Equipment Manufacturer (OEM) maintenance?
______________________________________________________________________________
9. What is the make and model of the continuous miner remote that you currently use?
______________________________________________________________________________
10. How many years have you been using that remote? __________
11. What is the make and model of the roof bolter that you currently use?
______________________________________________________________________________
12. How many years have you been using that roof bolter? __________
13. Do you use 3rd party or Original Equipment Manufacturer (OEM) maintenance for roof bolter maintenance?
______________________________________________________________________________
Section 3
For this section, you are being asked to provide information about the specific equipment you use at the mine where you work. For example, you likely use a multi-gas detector in your mine. What make and model do you use and approximately how many of those do you have? Please list the make and model for all of the items listed that you currently use at your mine.
If you use more than one model, please list them all and give the approximate number you have of each model.
If you do not use the item at your mine, please write Not Applicable (N/A) for your response. Finally, for each device, also mark who carries it on a regular basis. You will do this by putting an X next to each person who regularly carries the item.
Equipment Used
14. Multi-Gas Detector ______________________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
15. Methanometer (Methane Sniffer) ___________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
16. Anemometer (Air Flow)____________________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
17. Carried SCSR ___________________________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
18. Cached SCSR ___________________________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
19. Electronic Tracker _______________________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
20. Communication Device ___________________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
21. Cap Lamp _____________________________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
22. Personal dust monitor/Dust pump ___________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
23. Proximity Detector _______________________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)
24. Other Electronic Device (Please Specify) ____________________________________________________________
______________________________________________________________________ Quantity:_____________
• Section/Shift Foreman
• Fire Boss/ Mine Examiner
• Continuous Miner Operator
• Continuous Miner Helper
• Shuttle Car Operator
• Roof Bolter Operator
• Mechanic
• Scoop Operator
• Belt/Conveyor Man
• Utility/General Inside Laborer
• Rock Duster
• Electrician
• Other (Specify:________________________________)