COAL WORKERS' HEALTH SURVEILLANCE PROGRAM

Forms

Outside of a mine, cover for 2012 Mine Survey

Coal Contractor Planpdf icon

(OMB 0920-0020) (CDC/NIOSH 2.10) (July 2018)
The form and instructions should be used by underground coal mine operators’ when submitting a plan for their miner’s to receive chest x-rays at designated x-ray facilities. Coal mine operators must submit a plan and mine roster no later than 60 days after opening a new mine or 30 days when mine ownership is transferred. Mail to the address on the form or it may be emailed to CWHSP@cdc.gov.

Coal Mine Operator’s Planpdf icon (July 2018)

Radiographic Facility Certification Formpdf icon
(OMB 0920-0020) (CDC/NIOSH 2.11) (January 2015)
X-ray facilities should use this form to apply for certification and approval to take x-rays as part of the NIOSH program. Mail to the address on the form or it may be emailed to CWHSP@cdc.gov.

Spirometry Facility Certification Formpdf icon
(OMB 0920-0020) (CDC/NIOSH 2.14) (August 2014)
Complete this form to request to become a NIOSH-Approved Spirometry Facility. Mail to the address on the form or it may be emailed to CWHSP@cdc.gov.

Interpreting Physician Certification Documentpdf icon
(OMB 0920-0020) (CDC/NIOSH 2.12) (May 2016)
Physicians should complete this form to apply to take the NIOSH B Reader examination. Mail to the address on the form. Do NOT send this form electronically to NIOSH.

Miner Identification Form pdf icon[PDF – 2 MB]
En Españolpdf icon
(OMB 0920-0020) (CDC/NIOSH 2.9) (August 2019)
This form must be completed by the miner and accompany all x-rays sent to NIOSH for interpretation as part of the Coal Workers’ X-ray Surveillance Program. Mail to the address on the form. Do NOT send this form electronically to NIOSH. Print/Copy as a double-sided form.

Chest Radiograph Classification Formpdf icon (For official government use only)
(OMB 0920-0020) (CDC/NIOSH 2.8) (June 2014)
This form must be completed by the A or B Reader that interprets a chest radiograph for NIOSH as part of the Coal Workers’ X-ray Surveillance Program. Mail to the address on the form. Do NOT send this form electronically to NIOSH. Print/Copy as a double-sided form.

General Purpose Chest Radiograph Classification Formpdf icon (July 2014)
The general purpose form is provided as a convenience to certified B Readers and is not an official government form.

Spirometry Results Notification Formpdf icon (June 2016)

Respiratory Assessment Formpdf icon (June 2016)

Page last reviewed: September 12, 2019