Form Cdc/niosh 2.9 (E) - Miner Identification Document - Department Of Health And Human Services

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OMB No.: 0920-0020

MINER IDENTIFICATION DOCUMENT

FOR NIOSH USE ONLY

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

NIOSH Receipt Date:

COAL WORKERS’ HEALTH SURVEILLANCE PROGRAM (CWHSP)

NIOSH

FAX: 304-285-6058

DIRECTIONS FOR HEALTH FACILITY:

Coal Workers’ Health Surveillance Program

1095 Willowdale Road, M/S LB208

Please make sure that all items are completed. Then return form and results to:

Morgantown, WV 26505

Facility Name

Facility Number

Unit Number

Exam Type(s)

Health Program

Exam Date (MM/DD/YYYY)

Analog Radiograph

NIOSH CWHSP

Other (please specify)

Digital Radiograph

Spirometry

DIRECTIONS FOR THE MINERS

Miner’s Social Security Number

Sex

PLEASE COMPLETE AND MAKE ANY CORRECTIONS

TO THE INFORMATION BELOW (PLEASE PRINT)

Full SSN is optional; last 4 digits is required.

Miner’s Name (Last)

(First)

(MI)

Birth Date (MM/DD/YYYY)

Miner’s Mailing Address

City

State

Zip

Miner’s Telephone Number

Miner’s Email Address

(

)

Race (Check all that apply)

Ethnicity

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

Asian

White

Not Hispanic or Latino

Black or African American

Mine Name

MSHA Mine ID Number

If contractor, enter

Is your employer a

Mine Operator

Contractor

MSHA Contractor Number

Employers’ Name

City

State

When did you FIRST START WORK

Started

in the Coal Mine Industry?

Underground

Surface

Month

Year

Month

Year

How many TOTAL YEARS have you

Underground

Years

Surface

Years

worked in the Coal Mine Industry?

How many TOTAL YEARS have you

Years

worked Underground at the Face?

worked at Your Current Mine?

Do you wear a respirator (including dust masks) at work (exclude self-rescuers)?

Yes

If Yes, what type (Mark all that apply)

Dust Mask (disposable)

Half – face mask (other than disposable)

Full – face

Hood/Helmet

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.

Date Signed

Signature

(MM / DD /YYYY)

CDC/NIOSH 2.9 (E), Revised August 2016, CDC Adobe Acrobat 10.1, S508 Electronic Version, August 2016

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