Form 2.10 Coal Mine Operator's Plan

National Coal Workers' Health Surveillance Program (CWHSP)

Attachment 3 03 11 2015

Coal Mine Operator's Plan (CDC/NOISH (M) 2.10)

OMB: 0920-0020

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Attachment 3 -- Coal Mine Operator Plan – Form 2.10































































Form Approved

OMB No.: 0920-0020

Exp. Date xx/xx/20xx


COAL MINE OPERATOR’S PLAN

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

1. MSHA Mine Identification Number

2. Name of Company Officer in Charge of Program



RETURN TO

NIOSH

Coal Workers’ Health Surveillance Program

1095 Willowdale Road, M/S LB208

Morgantown, WV 26505

Fax: 304-28-6058




M

3. Email Address of Company Officer

4. Title of Company Officer in Charge



5. Name of Mine Operator/Company


6. Telephone Number


7. Street Address


8. City


9. State


10. Zip Code


11. Mine Name


12. County


13. # of Miners

14. Mine Mailing Address (Box number, Street)

15. City

16. State

17. Zip Code

Open period for obtaining examination
(6 months plus)

18. Begin Date

19. End Date

To be completed by NIOSH

20. Plan Approved Date

21. Plan Expiration Date

22. MSHA District

23. Mine Type

24. Mine Status


25. Remarks








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 treated in a secure manner and will not

be disclosed, unless otherwise compelled by law. I hereby assure that (1) the findings of any medical tests 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 radiographs 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 examinations made under this plan will be at no cost to the miner.

26. Signature of Mine Operator or Legal Representative


Date


27. Signature of NIOSH Approver (NIOSH ONLY)


Date


Complete the reverse side of form indicating each Facility Identification.

CDC/NIOSH (M) 2.10, Rev. 01/2015


Public reporting burden for 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-74, Atlanta, GA, 30333 ATTN: PRA (0920-0020). Do not send the completed form to this address.





28. Name(s) of Radiograph Facility(ies)


29. Facility Number

30. # Miles
from Mine

31. Days of Operation

32. Hours of Operation
























































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


34. Facility Number

35. # Miles from Mine

36. Days of Operation

37. Hours of Operation



















































CDC/NIOSH (M) 2.10, Rev. 01/2015


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