0920-0020-24IK Operators Plan

Form Approved
OMB No.: 0920-0020

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1. MSHA Mine Identification Number

COAL MINE OPERATOR'S PLAN
Department of Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

2. Name of Company Officer in Charge of Program

3. Email Address of Company Officer

NIOSH
RETURN COAL WORKERS’ HEALTH SURVEILLANCE PROGRAM
TO
1000 Frederick Lane, M/S LB208
Morgantown, WV 26508

4. Title of Officer in Charge

5. Name of Mine Operator/Company

6. Telephone Number

7. Street Address

8. City

9. State

13. # of Miners

12. County

11. Mine Name

14. Mine Mailing Address (Box number, Street)

Open period for obtaining examination
(6 months plus)
To be completed by NIOSH

22. MSHA District

15. City

16. State

18. Begin Date

19. End Date

20. Plan Approved Date

21. Plan Expiration date

23. Mine Type

24. Mine Status

10. Zip Code

17. Zip Code

25. Plan Duration (3, 4, or 5 years)

3
26. 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 held STRICTLY CONFIDENTIAL and
divulged only as specified by the above regulations. 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 X-Rays 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.
27. Signature of Mine Operator or Legal Representative

Date

28. Signature of NIOSH Approver (NIOSH ONLY)

Date

Complete the reverse side of form indicating each Facility Identification.
CDC/NIOSH (M) 2.10, Rev. 03/2021

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/ATSDR Reports
Clearance Officer, 1600 Clifton Road, MS H21-8, Atlanta, GA, 30333 ATTN: PRA (0920-0020). Do not send the completed form to
this address.

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29. Name(s) of X-Ray Facility(ies)

30. Facility
Number

31. # Miles
from Mine

32. Days of Operation

33. Hours of
Operation

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

35. Facility
Number

36. # Miles
from Mine

37. Days of Operation

38. Hours of
Operation

CDC/NIOSH (M) 2.10, Rev. 03/2021

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Instructions for Completion of Coal Mine Operator Plan (CDC 2.10)
Revised 03/2021
1……………

MSHA Mine Identification Number – Identification Number assigned by MSHA.

2…...………

Name of Company Officer In Charge of Program – Name of individual to be contacted relative to
implementation of plan.

3…………...
4……...……

Email Address of Company Officer – Email address of the company officer or of the primary contact at mine
operator.
Title of Company Officer in Charge – Title of individual listed in block #2.

5………...…

Name of Mine Operator/Company – Name of mine operator or parent company.

6……..........

Telephone Number – Telephone number for contact purposes for individual noted in block # 2.

7 thru 10…

Operator Mailing Address – Street, City, State and Zip Code of the mine operator or parent company.

11….....……

Mine Name – Specific name of mine (not company name).

12….....……

County – Name of county where mine is located.

13………….

# of Miners – Approximate number of miners employed or to be employed. Be sure a roster (with home mailing
addresses) of these employees is provided.
Mine Mailing Address – Street, City, State and Zip Code of the mine, not the company address (address where
approved plan will be sent).

14 thru 17…
18.........……

Open period for obtaining examination (Begin Date) – Beginning date of period during which miners will
have an opportunity for an x-ray and spirometry examination. If mine is new, program should begin within one
month of the date you submit your plan. If mine is not yet in operation, program should begin when hiring starts
to allow for pre-employment x-rays. Enter date (month, day, year) when examinations will begin.

19.........……

End Date – End date of 6-rnonth period during which miners will have opportunity for an x-ray and spirometry
examination. Program should end six months after beginning date. Enter date (month, day, year) when
examinations will stop (voluntary examinations only).

20.........……

Plan Approved Date – Date NIOSH approved the Mine Plan. COMPLETED BY NIOSH.

21.........……

Plan Expiration Date – Date the Mine Plan will expire. COMPLETED BY NIOSH.

22………….

MSHA District –The two-digit MSHA District code plus the two-digit Field Office Code. COMPLETED BY
NIOSH.
Mine Type – Specify type of mine: S for Surface or U for Underground.

23........……
24…….……
25........……

Mine Status – Specify mine status: A for Active, I for Intermittent (temporarily closed), or P for Permanently
Closed or Abandoned.
Plan Duration – Specify duration of the mine plan in years: 3, 4, or 5 (5 years is the default.)

30….....……

Remarks – Other pertinent information. Indicate if miners may be examined at facility on a walk-in basis, or if
appointment will be required. If appointments are required, indicate whether or not miners will be released from
work.
Operator Signature – Signature of Company Officer in block #2 (must be original, not stamp or copy) and date
plan is submitted.
NIOSH Approver Signature – Signature of NIOSH Approver (must be original, not stamp or copy) and date
plan was approved. COMPLETED BY NIOSH.
Name(s) of X-ray Facility(ies) – Facility(ies) where x-ray examinations are to be conducted. If mobile facility
is to be used, a local facility must also be named to conduct pre-employment and mandatory examinations.
Facility Number – NIOSH Facility Number (can be located in the facility list).

31….....……

# Miles from Mine – Distance from the facility to the mine in miles (enter 1 for mobile facilities).

32….....……

Days of Operation – Days of the week when miners may have their x-ray taken at the facility (i.e., Mon-Fri).

33….....……

Hours of Operation – Hours during each day when miners may have their x-ray taken at the facility (i.e.,
8:00 a.m. thru 4:00 p.m.). If mobile unit is to be used hours are usually one hour before and one hour after
shift change.
Name(s) of Spirometry Facility(ies) – Facility(ies) where spirometry examinations are to be conducted. If
mobile facility is to be used, a local facility must also be named to conduct pre-employment and mandatory
examinations.

26…….……
27…….……
28…….……
29….....……

34…….……

35….....……

Facility Number – NIOSH Facility Number (can be located in the facility list).

36…….……

# Miles from Mine – Distance from the facility to the mine in miles (enter 1 for mobile facilities).

37….....……

Days of Operation – Days of the week when miners may have their spirometry examined performed (i.e., MonFri).
Hours of Operation – Hours during each day when miners may have their spirometry examined performed (i.e.,
8:00 a.m. thru 4:00 p.m.). If mobile unit is to be used hours are usually one hour before and one hour after shift
change.

38….....……