Cm-911a - United States Department Of Labor
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1
2U.S. Department of Labor
Employment History
Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation
Reset
Print
Note: Persons are not required to respond to this collection of information unless it displays currently valid OMB
OMB No. 1215-0052
Expires: 08-31-08
control number.
Please complete as accurately as possible the miner's complete employment history. (Where employment was in
coal mining, specify whether the mine was a strip mine or an underground mine.) This report is authorized by law (30
U.S.C. 901 et. seq.) and required to obtain a benefit. While you are not required to respond, your cooperation is needed
to ensure that full and proper consideration is given to this claim. Disclosure of the social security number is voluntary.
Failure to disclose such number will not result in the denial of any right, privilege or benefit to which you may be entitled.
Miner's Name
Miner's Social Security Number
First Name
M.I.
Last Name
2.
4.
1.
3.
5.
Type of Industry
Occupation
Name and Address of Employer
Period of
Exposure to dust,
(Specify type
Employment
(City and State)
(Indicate if coal mining, extraction
gases, or fumes?
of work)
or preparation of coal, coal mine
construction, or transportation in
or around a coal mine, steel,
Mo/Yr
Mo/Yr
(Yes/No)
manufacturing or other)
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Form CM-911a
Rev. March 2003
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