2.9 Miner Identificaiton Document

National Coal Workers' Health Surveillance Program (CWHSP)

form 2.9 -proposed changes

Miner Identification Document (CDC/NIOSH 2.9)

OMB: 0920-0020

Document [docx]
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OMB No.: 0920-0020

MINER IDENTIFICATION DOCUMENT

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUAPTINAL SAFETY AND HEALTH

COAL WORKERS’ HEALTH SURVEILLANCE PROGRAM (CWHSP)

FOR NIOSH USE ONLY

NIOSH Receipt Date:


DIRECTIONS FOR HEALTH FACILITY:


PLEASE MAKE SURE THAT ALL ITEMS ARE COMPLETED. THEN RETURN FORM AND RESULTS TO:

NIOSH

Coal Workers’ Health Surveillance Program

1095 Willowdale Road, M/S LB208

Morgantown, WV 26505

FAX: 304-285-6058

Facility Name



Facility Number







Unit Number





Exam Type(s)


Analog Radiograph


Digital Radiograph


Spirometry


Radiograph Program


NIOSH CWHSP


Other (please specify)





Exam Date (MM/DD/YYYY)



/



/






DIRECTIONS FOR THE MINERS


PLEASE COMPLETE AND MAKE ANY CORRECTIONS

TO THE INFORMATION BELOW (PLEASE PRINT)

Miner’s Social Security Number




-



-






Full SSN is optional; last 4 digits is required.

Sex



M


F


Miner’s Name (Last)



(First)



(MI)



Birth Date (MM/DD/YYYY)



/



/






Miner’s Mailing Address



City



State




Zip







Miner’s Telephone Number

(




)




-






Miner’s Email Address



Race (Check all that apply)


American Indian or Alaska Native



Asian



Black or African American




Native Hawaiian or Other Pacific Islander



White


Ethnicity


Hispanic or Latino



Not Hispanic or Latino


Mine Name



MSHA Mine ID Number











Is your employer a


Mine Operator


Contractor


If contractor, enter

MSHA Contractor Number










Employers’ Name



City



State




When did you FIRST START WORK

in the Coal Mine Industry?

Started

Underground




/





Month


Year


Started

Surface




/





Month


Year


How many TOTAL YEARS have you

worked in the Coal Mine Industry?

Underground




Years

Surface




Years

How many TOTAL YEARS have you worked Underground at the Face?




Years

How many TOTAL YEARS have you

worked at Your Current Mine?




Years

Do you wear a respirator (including dust masks) at work (exclude self-rescuers)?

If Yes, what type (Mark all that apply)



No



Yes




Dust Mask (disposable)



Half – face mask (other than disposable)



Full – face



Hood/Helmet

I wish to participate in the Coal Workers’ Health Surveillance Program conducted under Section 203 of the Federal Mine Safety and Health Act of 1977 (30 U.S.843). I understand that reports of my examination will be mailed to me. I also understand that my results may be used to assess health and risks related to coal mining. My individual health information will be treated in a secure manner and information that can be connected to me as an individual will not be disclosed, unless otherwise compelled by law.

Signature



Date Signed

(MM / DD /YYYY)



/



/






CDC/NIOSH (M) 2. -- Rev. 01/159 --> Please complete Form on Reverse Side <--

Coal Mining Job History


COAL MINE JOB

MINE NAME/COMPANY

YEARS

UNDERGROUND

SURFACE

COAL

MINE


Please List in Order Any Coal Mine Job You Have Held and Mine Name

(if information is provided please correct and/or update)

Start

Year

End

Year



Face

Nonface

Surface



Example

Continuous Miner Operator


Mine Name/Company

1985

1990

X






























































































































































































Have You Ever Worked in Any Mine Other than Coal?



No



Yes

If Yes, please record number of years worked:


Metal mines

(For example, lead,

copper, gold, silver)

Surface




years worked

Nonmetal mines

(For example,

salt, phosphate, limestone)

Surface




years worked


Underground




years worked

Underground




years worked


Have You Ever Worked for More than 1 Year in Any Other Dusty Job?



No



Yes

If Yes, please record number of years:


Work with asbestos, vermiculite or talc




years

In foundry, pottery, or abrasive manufacturing




years


Tunneling, drilling, quarrying, sand blasting




years

Welding, cutting, or grinding metals




years


Road construction, jack hammer, masonry saw




years

Other dusty job (please specify)




years







Public reporting burden of this collection of information is estimated to average 20 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 the burden to CDC, Project Clearance Officer, 1600 Clinton Road, MS E-11, Atlanta, GA 30333, ATTN: PRA (0920-0020). Do not send the completed form to this address.


CDC/NIOSH (M) 2.9, Rev. 01/15


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