Form CM-913 Description of Coal Mine Work and Other Employment

Description of Coal Mine Work and Other Employment

U. S. Department of Labor

Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation

This report is authorized by the Black Lung Benefits Act (30 USC 901 et seq.).			OMB No. 1240-0035 Expires: XX/XX/XXXX
Miner's Name (Last, First, Middle Initial)		Miner's Last Four Digits of Social Security Number or DOL's Case ID Number

PART I - DESCRIPTION OF MOST RECENT COAL MINE WORK

1. Job Title	2. Dates Worked (mm/dd/yyyy) From: To:
3. Highest or current rate of pay	4. Number of days worked per week

5. Please provide the following information for the MOST RECENT COAL MINE EMPLOYMENT. If you are still working in coal mine employment, describe your current position.

5a. What is the name of the coal mine operator and the state where you/the miner most recently worked?

5b. While working as a coal miner, did you/the miner ever use personal protective equipment? If yes, please explain if and how it prevented breathing coal mine dust.

FOR UNDERGROUND WORK

5c. How did you/the miner approach the coal seam?

tunneling slope a shaft a drift mine other 5d. What was the height of the coal seam?

5e. Where was the work being done? (examples: in the shaft, at the face)

5f. What type of mining equipment did you/the miner use? (examples: continuous miner, conventional mining, longwall)

FOR SURFACE WORK

5g. Where was the work being done? (examples: tipple, warehouse)

5h. What type of mining equipment did you/the miner use? (examples: dozer operator, haulage truck driver)

5. Describe the exertional requirements of the most recent coal mine job. Sitting for hours per day.

Standing for hours per day.

Crawling Lifting

(distance) for pounds

hours per day. times per day.

(example: 25 pounds 10 times per day).

Lifting Lifting

pounds pounds

times per day. times per day.

Carrying

pounds (distance)

times per day.

(example: 20 pounds 50 feet 15 times per day)

Carrying Carrying

pounds (distance)

pounds (distance)

times per day. times per day.

5. Did the most recent coal mine job involve:

   1. The use of tools, machines or equipment?

Yes No

2. Were you/the miner exposed to dust or fumes? Yes No

3. Technical knowledge or special skills? Yes No

4. Any supervisory responsibilities? Yes No

Please explain all "YES" answers. For example, state the specific type of tools, machines or equipment you/the miner used; what type of dust, fumes or gas you/the miner were exposed to during the operation of tools, machines or equipment (examples: rock dust, gas or diesel fumes); the nature of any technical knowledge or special skills you/the miner needed; and the nature of any supervisory duties, including the number and type of employees you/the miner supervised, the extent to which they had to be supervised, etc.

5. Were you/the miner ever transferred from a previous job due to health reasons? (example: Did you/the miner ever receive a 90 Miner Status from Mine Safety and Health Administration?)

If "YES", provide a copy and the following information:

a. Previous Job b. Job Transferred To

e. If coal mine work has stopped, give reason and last date worked:

Part II - OTHER COAL MINE WORK

5. List all other coal mine jobs you/the miner worked for at least one year.

Job Title

Dates Worked

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

10. Job Title		11. Type of business or industry
12. Dates Worked From: To:	13. Highest or current rate of pay		14. Number of days worked per week

PART III: DESCRIPTION OF MOST RECENT NON-COAL MINE EMPLOYMENT DESCRIBE MOST RECENT NON-COAL MINE EMPLOYMENT

15. Describe the duties of this job in your own words:

15. Describe the exertional requirements required by the NON-COAL MINE job. Sitting for hours per day.

Standing for hours per day.

Lifting

pounds

times per day.

(example: 25 pounds 10 times per day).

Lifting Lifting

pounds pounds

times per day. times per day.

Carrying

pounds (distance)

times per day.

(example: 20 pounds 50 feet 15 times per day)

Carrying Carrying

pounds (distance)

pounds (distance)

times per day. times per day.

15. Did the NON-COAL MINE job involve:

    1. The use of tools, machines or equipment?

    2. Were you exposed to dust or fumes?

    3. Technical knowledge or special skills?

    4. Any supervisory responsibilities?

Yes No

Yes No

Yes No

Yes No

Please explain all "YES" answers. For example, state the specific type of tools, machines or equipment you/the miner used; what type of dust, fumes or gas were you/the miner exposed to during the operation of tools, machines or equipment (examples: construction dusts, gas or diesel fumes); the nature of any technical knowledge or special skills you/the miner needed; and the nature of any supervisory duties, including the number and type of employees you/the miner supervised, the extent to which they had to be supervised, etc.

15. If NON-COAL MINE work has stopped, give reason and last date worked:

PART - IV

15. Use this section for additional space to answer any previous question, or to provide any other information you feel would be helpful. Please refer to previous questions by the corresponding number. If more space is needed, use a blank sheet and attach.

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. A response is required in order for your benefit claim to receive proper consideration. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Coal Mine Workers’ Compensation, Room C-3526, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

NOTE: Persons are not required to respond to this collection of information unless it displays a current valid OMB control number.

Privacy Act Statement

The following information is provided in accordance with the Privacy Act of 1974, 5 USC 552a. (1) Submission of this information is required under the Black Lung Benefits Act. (2) The information will be used to determine eligibility for and the amount of benefits payable under the Act. (3) The information may be used by other agencies or persons in handling matters relating, directly or indirectly, to the subject matter of the claim, including potentially liable coal mine operators and their insurance carriers; medical professionals in obtaining medical services or evaluations; contractors providing automated data processing services to the Department of Labor; representatives of the parties to the claim; and federal, state or local agencies in obtaining information about eligibility for benefits. (4) Furnishing all requested information will facilitate the claims adjudication process; and the effects of not providing all or any part of the requested information may delay the process, or result in an unfavorable decision or a reduced level of benefits. (Disclosure of your social security number is voluntary; failure to disclose such number will not result in the denial of any right, benefit, or privilege to which an individual may be entitled.) (5) This information is included in Systems of Records DOL/OWCP-2 and DOL/OWCP-9, published at 81 Federal Register 25765, 25858, 25866 (April 29, 2016), or as updated and republished.

Notice

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or the claims examiner to ask about this assistance.

I certify that the information given by me on and in connection with this form is true and correct to the best of my knowledge and belief. I am also fully aware that any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or payment under this title shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, subject to a fine of not more than

$1,000, or by imprisonment for not more than one year, or both.

Form CM-913 Rev.