0920-0020-24IK Miner Identification

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OMB No.: 0920-0020

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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)

NIOSH Receipt Date:
NIOSH
Coal Workers’ Health Surveillance Program
1000 Frederick Lane, M/S LB208
Morgantown, WV 26508
Radiography Facility Number

DIRECTIONS FOR HEALTH FACILITY:
Please make sure that all items are completed. Then return form and results to:
Facility Name
Exam Type(s)

Health Program
NIOSH CWHSP

Analog Radiograph

Spirometry Facility Number

Other (please specify)

Digital Radiograph

Unit Number
Unit Number

Exam Date (MM/DD/YYYY)

/

/

Spirometry
DIRECTIONS FOR THE MINERS
PLEASE COMPLETE AND MAKE ANY CORRECTIONS
TO THE INFORMATION BELOW (PLEASE PRINT)
Miner’s Name (Last)

Miner’s Social Security Number

-

-

(First)

Full SSN is optional
Last 4 digits required

Birth Date (MM/DD/YYYY)

(MI)

/
Miner’s Mailing Address

City

Miner’s Telephone Number

Zip

Miner’s Email Address

White

Asian

Middle Eastern or North African

Black or African American

Native Hawaiian or Pacific Islander

Mine Operator

/
State

What is your race and/or ethnicity? (Check all that apply)
American Indian or Alaska Native
Hispanic or Latino

Is your employer a

FAX: 304-285-6058

Contractor

What sex were you
assigned at birth on your
original birth certificate?

Other:

M

F

Mine Name

MSHA Mine ID Number

If contractor, enter MSHA Contractor Number

Employers’ Name

City

State

When did you start in the Coal Mine Industry?

Month/Year:

Have you EVER worked UNDERGROUND at a coal Mine?

No

/
Yes

If yes, how many TOTAL years have you worked UNDERGROUND at a coal mine?

Total # of Years:

If yes, how many TOTAL years have you worked UNDERGROUND at the FACE?

Total # of Years:

Have you EVER worked on the SURFACE at a coal mine?
If yes, how many TOTAL years did you work at the SURFACE?
Do you wear a respirator (including dust masks) at work (exclude self-rescuers)?

No

Yes

Total # of Years:
No

Yes

If yes, what type (mark all that apply)
Dust Mask (disposable)
CDC/NIOSH 2.9 (M), Rev. 12/2024

Half – face mask (other than disposable)
--> Please complete Form on Page 2 <--

Full – face

Hood/Helmet

Miner's Name (Last, First MI)

Coal Mining Job History
List in Order Any Coal Mine Job You Have Held and Mine Name (if information is provided please correct and/or update).
If you had >1 position during the same time frame, list the primary position.
COAL MINE JOB
Example
Continuous Miner Operator

MINE NAME/COMPANY

Start
Year

End
Year

Mine Name/Company

1985

1990

Have you EVER worked at a Metal/Non-Metal mine (gold, limestone, etc.)?
If yes, How many TOTAL years did you work UNDERGROUND?
If yes, how many TOTAL years did you work at the SURFACE?

No

UNDERGROUND
Face Nonface Surface

Yes

Total # of Years:
Total # of 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)

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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/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.