Form 0920-24IK Request for Medcial Record

Public reporting burden of this collection of information is estimated to average 5
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 NE, MS H21-8, Atlanta, Georgia
30333 ATTN: PRA (0920-0020).

Form Approved
OMB No. 0920-0020

NIOSH Coal Workers' Health
Surveillance Program
(CWHSP)

Request for Medical Records
Please provide answers to all of the bulleted information below and mail to:
National Institute for Occupational Safety and Health
Coal Workers’ Health Surveillance Program
Attention: Diana Cale/Jennifer Orrahood – Mailstop LB208
1000 Frederick Lane
Morgantown, WV 26508
or
FAX: (304) 285-6058
Today’s date____________________________
I request a copy of my:
Chest Radiograph (x-ray) dated

Radiograph Interpretation Sheets
Breathing test (spirometry) results
Send my medical records to:
My home

My Personal Physician
Other
Address where medical records should be sent:
Name _____________________________________________________
Street _____________________________________________________
City ____________________________ State________ Zip________
Phone # ( _____ ) _____________________
The last 4 digits of my social security number are: _______________________
My birthdate is:___________________________________
If you need to contact me for clarifications on this request, I can be reached at:

Home Phone # ( _____ ) _____________________
Work Phone # ( _____ ) _____________________
“I hereby certify that I am ______________________________________and understand that
(print your name here)

knowing and willful request for, or acquisition of, records pertaining to an individual under false
pretenses is a criminal offense under the Privacy Act, subject to a $5,000 fine.”
Signature _____________________________________
Required before NIOSH can send copies of medical records.

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