Coal Workers’ Health Surveillance Program

Forms

B Reader Scheduling Form [PDF – 42 KB]
Physicians interested in applying for the NIOSH B Reader exam must complete this form. Email the completed form and a copy of their current medical license to CWHSP@cdc.gov. B Readers will receive a confirmation email with their exam date and additional information.

Chest Radiograph Classification Form [PDF – 824 KB] (For official government use only)
(OMB 0920-0020) (CDC/NIOSH 2.8) (March 2021)
This form must be completed by a B Reader that interprets chest radiographs for NIOSH as part of the Coal Workers’ Health Surveillance Program. B Readers must submit the form electronically to the Coal Workers’ Health Surveillance Program. Print/Copy as a double-sided form.

Coal Contractor Plan [PDF – 166 KB]
(OMB 0920-0020) (CDC/NIOSH 2.10) (March 2021)
Form and instructions for Contractors to use when submitting a mine plan for their employees to receive chest x-rays at designated x-ray facilities. Contractors should also submit a Part 48 trained employee roster that includes names and home addresses to include with the plan.

Email completed forms to CWHSP@cdc.gov. If unable to send electronically, the form can be sent by mail using the address listed on the form.

Coal Mine Operator’s Plan [PDF – 712 KB] (March 2021)
Form and instructions for coal mine operators’ when submitting a plan for their miners to receive chest x-rays at designated x-ray facilities. Coal mine operators must submit a plan and Part 48 trained employee roster that includes names and home addresses:

• No later than60 days after opening a new mine

or

• 30 days when mine ownership is transferred.

Email completed forms to CWHSP@cdc.gov. If unable to send electronically, the form can be sent by mail using the address listed on the form.

General Purpose Chest Radiograph Classification Form (July 2020)
This form is intended to be used by certified B Readers and is not an official government form.

Miner Identification Form [PDF – 2 MB]
En Español
(OMB 0920-0020) (CDC/NIOSH 2.9) (August 2022)
This form must be completed and signed by a miner and submitted electronically along with the miner’s chest x-ray to NIOSH using the program specified by NIOSH. Print/Copy as a double-sided form.

Radiographic Facility Certification Form [PDF – 645 KB]
(OMB 0920-0020) (CDC/NIOSH 2.11) (March 2021)
Complete this request form to become a NIOSH-Approved Radiograph Facility and take x-rays as part of NIOSH’s CWHSP. Email completed forms to CWHSP@cdc.gov. If unable to send electronically, the form can be sent by mail using the address listed on the form.

Request for Medical Records Form [PDF – 168 KB]
The Request for Medical Records Form should be completed by miners wishing to receive copies of their CWHSP chest x-rays and related files. The form must be completed in its entirety, signed, and returned to NIOSH by mail or fax listed on the form.

Respiratory Assessment Form [PDF – 224 KB] (March 2021)
This form must be completed by a NIOSH-approved spirometry facility during the initial spirometry test and at each subsequent spirometry test. Facilities must submit the form electronically to the Coal Workers’ Health Surveillance Program. Print/Copy as a double-sided form.

Spirometry Facility Certification Form [PDF – 933 KB]
(OMB 0920-0020) (CDC/NIOSH 2.14) (March 2021)
Complete this request form to become a NIOSH-Approved Spirometry Facility. Email completed forms to CWHSP@cdc.gov. If unable to send electronically, the form can be sent by mail using the address listed on the form.

Spirometry Results Notification Form [PDF – 225 KB] (March 2021)
This form must be completed by a NIOSH-approved spirometry facility prior to each spirometry test session. The form should be used to identify possible contraindications to testing or factors that might affect testing results. Facilities must submit the form electronically to the Coal Workers’ Health Surveillance Program. Print/Copy as a double-sided form.