0920-24IK Consent Release and History Form

Form Approved – CDC/NIOSH 2.6
OMB No. 0920-0020

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
Consent, Release and History Form for Autopsy
Federal Coal Mine Health and Safety Act of 1969
I, ____________________________________, ______________________________ of ________________________________ do hereby
Name
Relationship
Name of deceased miner
authorize the performance of an autopsy (________________________________) on said deceased. I understand that the report and certain
Limitation, if any, on autopsy
tissue (as necessary) will be released to the United States Public Health Service and to ____________________________________________.
Name of physician securing autopsy
I understand that any claims in regard to the deceased for which I may sign a general release of medical information will result in the release of the
information from the Public Health Service. I further understand that I shall not make any payment for the autopsy.
OCCUPATIONAL AND MEDICAL HISTORY
1. Date of Birth of Deceased
2. Social Security Number of Deceased

___________________________
Month
Day
Year
__________________________

Note: Full SSN is optional; last 4 digits is required
3. Date and Place of Death
4. Place of Last Mining Employment:
Name of Mine
Name of Mining Company
Mine Address

_____________________________________________
Month, Day, Year
City, County, State
________________________________________
________________________________________
_________________________________________
_________________________________________

5. Date of Last Work or Retirement ___________________
6. Last Job Title at Mine of Last Employment ________________________________________
(specify surface or underground)
e.g., Continuous Miner Operator, Motorman, Foreman, etc.
7. Job Title of Principal Mining Occupation (the job to which miner devoted the most number of years)
(specify surface or underground)
_________________________________________________
8. Smoking History of Miner:
(a) Did the miner ever smoke cigarettes?
Yes _____ No _____
(b) If yes, for how many years?
______Years
(c) If yes, how many cigarettes per day did the miner smoke on average? ______ Number of cigarettes per day
(d) Did the miner smoke cigarettes up until the time of death?
Yes ____ No ____
(e) If no to (d), for how long before death had the miner stopped smoking cigarettes? __________
9. Total Years in Surface Coal Mining, by State (if known)

_______ _______________
(Years)
(State)
10. Total Years in Underground Coal Mining, by State (if known)
_______ _______________
(Years)
(State)
_______________________________
Signature
_______________________________
Street
_______________________________
City
State
Zip
_______________________________
Telephone
_______________________________
Date

Public reporting burden for this collection of information is estimated to average 15 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, Georgia 30333; ATTN: Paperwork Reduction Project (0920-0020)