CM-911a Employment History

Employment History

U.S. DEPARTMENT OF LABOR

Office Of Workers' Compensation Programs

Division Of Coal Mine Workers' Compensation

Please provide as accurately as possible the miner's COMPLETE coal mine employment history. This report is authorized by law (30 U.S.C. 901 et. seq.) and required to obtain a benefit. While you are not required to respond, your cooperation is needed to ensure that full and proper consideration is given to this claim. Disclosure of the social security number is voluntary. Failure to disclose such number will not result in the denial of any right, privilege, or benefit to which you may be entitled.

OMB No. xxxx-xxxx

Expires xx/xx/xxxx



1. Miner's Name (First, Middle, Last):

2. Miner’s Social Security Number:

3. DOL’s Case ID Number:

4. Your Mailing Address (Number, Street, Apt. No., PO Box): 5. City, State, and Zip Code:

6. Your Email Address: 7. Your Telephone Number:

PART I - DESCRIPTION OF MOST RECENT COAL MINE WORK

8. Job Title Most Recent Coal Mine Employment:	9. Dates Worked (mm/dd/yyyy): From: To:
10. Name of Most Recent Coal Mine Operator:______________ __________________________________________________ a. State of Most Recent Coal Mine Employment: ______	11. Number of days worked per week: _________ a. Hourly Pay rate: _____________ b. Hours worked per day: ________ c. Approximate Annual Earnings: _________

12. Where was your/the miner’s work location?

¨ Coal Preparation Facility ¨Coal Mine-Underground Mine ¨ Coal Mine-Surface Mine ¨ Other________________

a. What type of Coal Mine work was being performed?

¨ Extraction ¨ Preparation ¨ Transportation ¨ Maintenance ¨ Construction ¨ Other If other, please explain:

b. Were you/the miner exposed to dust, gases, or fumes? ¨ YES ¨ NO If yes, please indicate how often, how long, and how much exposure.

c. Please describe your/the miner’s most recent Coal Mine Employment duties.

d. Where was the work being done? (Examples: in the shaft, at the face, tipple, warehouse, etc.)

e. What type of mining equipment did you/the miner use? (Continuous miner, longwall, dozer, haulage driver truck, etc.)

f. Why did your/the miner’s Coal Mine Employment end?

13. Exertional requirements of the most recent coal mine job.

How many hours a day did you/the miner sit down?	¨Never ¨Less than 1 hour ¨1-4 hours per day ¨4-8 hours per day ¨More than 8 hours per day
How many hours a day did you/the miner stand up?	¨Never ¨Less than 1 hour ¨1-4 hours per day ¨4-8 hours per day ¨More than 8 hours per day
How many hours a day did you/the miner crawl?	¨Never ¨Less than 1 hour ¨1-4 hours per day ¨4-8 hours per day ¨More than 8 hours per day
How heavy were the items you/the miner had to lift?	¨ Less than 10 pounds ¨ 10-25 pounds ¨ 26-50 pounds ¨ More than 50 pounds
How often did you/the miner lift those items?
How heavy were the items you/the miner had to carry?	¨ Less than 10 pounds ¨ 10-25 pounds ¨ 26-50 pounds ¨ More than 50 pounds
How far and how often did you/the miner carry those items?

Part II - OTHER COAL MINE WORK

List all Coal Mine Employment. Start with the next most recent position.

14. Name of Employer, City and State of Employment Site	15. Period of Employment (mm/dd/yyyy)	16. Location of Work	17. Type of Coal Mine Work	18. Occupation and Job Duties	19. Exposure to dust, gases, or fumes?
Name City State	Start Date: End Date:	¨ Coal Preparation Facility ¨ Coal Mine- Underground ¨ Coal Mine- Surface ¨ Other location If other location, please explain:	¨ Extraction ¨ Preparation ¨ Transportation ¨ Maintenance ¨ Construction ¨ Other If other, please explain:	Occupation: Job Duties:	¨ No ¨ Yes If yes, please indicate how often, how long, and how much exposure:
Name City State	Start Date: End Date:	¨ Coal Preparation Facility ¨ Coal Mine- Underground ¨ Coal Mine- Surface ¨ Other location If other location, please explain:	¨ Extraction ¨ Preparation ¨ Transportation ¨ Maintenance ¨ Construction ¨ Other If other, please explain:	Occupation: Job Duties:	¨ No ¨ Yes If yes, please indicate how often, how long, and how much exposure:
Name City State	Start Date: End Date:	¨ Coal Preparation Facility ¨ Coal Mine- Underground ¨ Coal Mine- Surface ¨ Other location If other location, please explain:	¨ Extraction ¨ Preparation ¨ Transportation ¨ Maintenance ¨ Construction ¨ Other If other, please explain:	Occupation: Job Duties:	¨ No ¨ Yes If yes, please indicate how often, how long, and how much exposure:
Name City State	Start Date: End Date:	¨ Coal Preparation Facility ¨ Coal Mine- Underground ¨ Coal Mine- Surface ¨ Other location If other location, please explain:	¨ Extraction ¨ Preparation ¨ Transportation ¨ Maintenance ¨ Construction ¨ Other If other, please explain:	Occupation: Job Duties:	¨ No ¨ Yes If yes, please indicate how often, how long, and how much exposure:
Name City State	Start Date: End Date	¨ Coal Preparation Facility ¨ Coal Mine- Underground ¨ Coal Mine- Surface ¨ Other location If other location, please explain:	¨ Extraction ¨ Preparation ¨ Transportation ¨ Maintenance ¨ Construction ¨ Other If other, please explain:	Occupation: Job Duties:	¨ No ¨ Yes If yes, please indicate how often, how long, and how much exposure:
Name City State	Start Date: End Date:	¨ Coal Preparation Facility ¨ Coal Mine- Underground ¨ Coal Mine- Surface ¨ Other location If other location, please explain:	¨ Extraction ¨ Preparation ¨ Transportation ¨ Maintenance ¨ Construction ¨ Other If other, please explain:	Occupation: Job Duties:	¨ No ¨ Yes If yes, please indicate how often, how long, and how much exposure:
Name City State	Start Date: End Date:	¨ Coal Preparation Facility ¨ Coal Mine- Underground ¨ Coal Mine- Surface ¨ Other location If other location, please explain:	¨ Extraction ¨ Preparation ¨ Transportation ¨ Maintenance ¨ Construction ¨ Other If other, please explain:	Occupation: Job Duties:	¨ No ¨ Yes If yes, please indicate how often, how long, and how much exposure:
Name City State	Start Date: End Date:	¨ Coal Preparation Facility ¨ Coal Mine- Underground ¨ Coal Mine- Surface ¨ Other location If other location, please explain:	¨ Extraction ¨ Preparation ¨ Transportation ¨ Maintenance ¨ Construction ¨ Other If other, please explain:	Occupation: Job Duties:	¨ No ¨ Yes If yes, please indicate how often, how long, and how much exposure:

PART III: ADDITIONAL COAL MINE WORK INFORMATION

Please note that your entitlement to benefits will in no way be impacted by your responses in this Part.

20. While working as a coal miner, did you/the miner ever use personal protective equipment? ¨ Yes ¨ No

a. If yes, please provide additional details. What personal protective equipment did you/the miner use? How often did you/the miner utilize the equipment?

b. Do you/the miner believe the personal protective equipment prevented breathing coal mine dust? Please explain:

21. 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?) ¨ Yes ¨ No

a. If yes, what was the date of transfer? b. What was the reason of transfer?

PART IV: OTHER RELEVANT INFORMATION

22. Have you/the miner been exposed to dust, gases, or fumes during any employment outside of coal mine employment? If so, what was your/the miner’s occupation, job duties, and length of employment where the exposures took place? How often (frequency), how long (duration), and how much (extent) were your/the miner’s exposures?

23. Did you/the miner ever have any hobbies or interests where you/the miner have been exposed to dust, gases, or fumes? If so, please describe.

24. 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.

I hereby 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.
25. Signature of claimant (First, middle, last)		26. Date (Month, day, year)
Witnesses are required only if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the applicant must sign below, giving their full address.
27. Signature of witness	28. Signature of witness
29. Address (Number, Street, City, State & Zip Code)	30. Address (Number, Street, City, State & Zip Code)
NOTE: Persons are not required to respond to this collection of information unless it displays currently valid OMB control Number.
PRIVACY ACT NOTICE In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) the Black Lung Benefits Act (BLBA) (30 U.S.C. 901 et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives and maintains personal information, relative to this application, on claimants and their immediate families; (2) information obtained by OWCP will be used to determine eligibility for benefits payable under the BLBA; (3) information may be given to other government agencies, coal mine operators potentially liable for payment of the claim or to the insurance carrier or other entity which secured the operator's compensation liability, contractors providing automated data processing services to the Department of Labor; and representatives of the parties to the claim; (4) infrmation may be given to physicians or other medical service providers for use in providing treatment, making evaluations and for other purposes relating to the medical management of the claim; (5) information may be given to the Department of Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to render decisions with respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local agencies for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have been paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law; (7) disclosure of the claimant's or deceased miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary, and the SSN and/or TIN and other information maintained by the OWCP may be used for identification and for other purposes authorized by law; (8) failure to disclose all requested information, may delay the processing of this claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits; and (9) this information is included in a System of Records, DOL/OWCP-2 published at 81 Federal Register 25765, 25858 (April 29, 2016) or as updated and republished.
PUBLIC BURDEN STATEMENT Public reporting burden for this collection of information is estimated to average 60 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. 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-3520, 200 Constitution Avenue, N. W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
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 for assistance.

TWO FILING OPTIONS:

1. To file electronically, submit completed form and accompanying documentation to the C.O.A.L. Mine Portal: https://eclaimant.dol.gov/portal/?program_name=BL

2. To file by mail, submit completed form and accompanying documentation to:

U.S. Department of Labor OWCP/DCMWC

Central Mail Room

PO Box 8307

London, KY 40742-8307

pg. 2 CM-911a (draft)