0920-0020 Miner Identification Document Form M 2.9 25MAR2019

OMB No.: 0920-0020

MINER IDENTIFICATION DOCUMENT

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL 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 FAX: 304-285-6058

Coal Workers’ Health Surveillance Program

1095 Willowdale Road, M/S LB208

Morgantown, WV 26505

Facility Name

Radiograph Facility Number

Unit Number

Exam Type(s)

	Analog Radiograph
	Digital Radiograph
	Spirometry

Health Program

NIOSH CWHSP

Other (please specify)

Spirometry Facility Number

Unit Number

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

CDC/NIOSH 2.9 (E), Revised 02/2019

--> Please complete Form on Page 2 <--

Miner’s Name (Last, First MI)

Coal Mining Job History

COAL MINE JOB

MINE NAME/COMPANY

YEARS

UNDERGROUND

SURFACE

COAL

MINE

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

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)

/

/

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 2.9 (E), Revised 02/2019