Form 2.18 Coal Contractor Plan

National Coal Workers' Health Surveillance Program (CWHSP)

Attachment 4 03 11 2015

Coal Contractor Plan CDC/NIOSH 2.18

OMB: 0920-0020

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Attachment 4 -- Coal Contractor Plan – Form 2.18







































































Form Approved

OMB No.: 0920-0020

Exp. Date xx/xx/20xx


COAL CONTRACTOR PLAN

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

1. MSHA Contractor 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: 304-285-6058


3. Email Address of Company Officer


4. Title of Company Officer in Charge




5. Name of Company


6. Telephone Number


7. Street Address


8. City


9. State


10. Zip Code



11. # of Miners.

Open Period for Obtaining Examination
(6 months plus)

12. Begin Date


13. End Date


To be completed by NIOSH

14. Plan Approved Date


15. Plan Expiration Date


16. MSHA District

9998

17. Type

C

18. Status


19. 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 radiograph 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.

20. Signature of Company or Legal Representative



Date


21. Signature of NIOSH Approver (NIOSH ONLY)


Date


Complete the reverse side of form indicating

each Service Center/Site Location and each Facility Identification.

CDC/NIOSH (M) 2.18, Rev. 01/2015


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





22. State/County of Company and all Service Centers or Site Locations where miners are employed
















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


24. Facility

Number

25. # Miles from

Service Center

26. Days of Operation

27. Hours of Operation














































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


29. Facility Number

30. # Miles from Service Center

31. Days of Operation

32. Hours of Operation









































CDC/NIOSH (M) 2.18, Rev. 01/2015

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