0920-24IK Contractor Plan

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Form Approved
OMB No.: 0920-0020
1. MSHA Contractor Identification Number

COAL CONTRACTOR 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

NIOSH
COAL WORKERS’ HEALTH SURVEILLANCE PROGRAM
RETURN 1000 Frederick Lane, M/S LB208
TO
Morgantown, WV 26508
FAX: 304-285-6058

3. Email Address of Company Officer

5. Name of Company

6. Telephone Number

7. Street Address

4. Title of Company Officer in Charge

8. City

9. State

10. Zip Code

11. # of Miners.

Open Period for Obtaining Examination
(6 months plus)

12. Begin Date

13. End Date

To be completed by NIOSH

14. Plan Approved Date

15. Plan Expiration Date

16. MSHA District

18. Status

17. Type

9998

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

C

5

20. 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 treated in a secure manner and will not
be disclosed, unless otherwise compelled by law. 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 radiograph 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.
Date

21. Signature of Company or Legal Representative

10/06/2021
Date

22. Signature of NIOSH Approver (NIOSH ONLY)

10/06/2021

Complete the reverse side of form indicating
each Service Center/Site Location and each Facility Identification.
CDC/NIOSH (M) 2.18, 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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23. State/County of Company and all Service Centers or Site Locations where miners are employed

24. Name(s) of Radiograph Facility(ies)

25. Facility
Number

26. # Miles from
27. Days of Operation
Service Center

28. Hours of
Operation

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

30. Facility
Number

31. # Miles from
Service Center 32. Days of Operation

33. Hours of
Operation

CDC/NIOSH (M) 2.18, Rev. 03/2021

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Instructions for Completion of Coal Contractor Plan (CDC 2.18)
Rev. 03/2021
If you have employees requiring MSHA Part 48 Training, please complete the form using the instructions below then
return the completed form to NIOSH.
Otherwise, complete #1-10, enter “None” in #11 and enter “No Part 48 employees” in #19, Sign and Date #20 then
return the form to NIOSH.
1……………

MSHA Contractor 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……………

Email Address of Company Officer –Email of company officer or primary contact at contractor’s office.

4……...……

Title of Company Officer in Charge – Title of individual listed in block #2.

5………...…

Name of Company – Name of company.

6……..........

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

7 thru 10…

Company Mailing Address – Street, City, State and Zip Code of the of company.

11….....……

14.........……

# of Miners – Approximate number of miners employed or to be employed who require MSHA Part 48
Training. Be sure a roster (with home mailing addresses of these employees is provided).
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 company is new, program should begin within
one month of the date you submit your plan. If company 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.
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).
Plan Approved Date – Date NIOSH approved the Plan. COMPLETED BY NIOSH.

15.........……

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

16.........……

MSHA District – For contractors, the MSHA District is always 9998. COMPLETED BY NIOSH.

17.........……

Type – For contractors, the type is always C (for contractor). COMPLETED BY NIOSH.

18…….……

Status – Specify company status: A for Active or P for Permanently Closed or out of mining business.

19........……

Plan Duration – Specify duration of the contractor plan in years: 3, 4, or 5 (5 years is the default)

20…….……

Remarks – Other pertinent information. Indicate if miners may be examined at facility on a walk-in basis, or if
an appointment will be required. If appointments are required, indicate whether or not miners be released from
work.
Company Officer 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 approved. COMPLETED BY NIOSH.
State/County of Company and all Service Centers or Site Locations where miners are employed – State
abbreviation and county name where miners are employed. All locations should be listed.
Name(s) of X-ray Facility(ies) – Facility(ies) where x-ray examinations are to be conducted for each location
listed in #22. 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).

12.........……

13.........……

21…….……
22.
23…….……
24….....……
25….....……
26….....……
27….....……
28….....……
29…….……
30….....……
31…….……
32….....……
33….....……

# Miles from Service Center – Distance from the facility to the company or service center/site location in miles
(enter 1 for mobile facilities).
Days of Operation – Days of the week when miners may have their x-ray taken (i.e., Mon-Fri).
Hours of Operation – Hours during each day when miners may have their x-ray taken at 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 for each
location listed in #22. If mobile facility is to be used, a local facility must also be named to conduct preemployment and mandatory examinations.
Facility Number – NIOSH Facility Number (can be located in facility list).
# Miles from Service Locations – Distance from the facility to the company or service center/site location in
miles (enter 1 for mobile facilities)
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 at
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.