Coal Workers’ Health Surveillance Program: Forms

Forms

Coal Contractor Plan [PDF – 166 KB]
(OMB 0920-0020) (CDC/NIOSH 2.10) (March 2021)
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 Plan [PDF – 712 KB] (March 2021)

Radiographic Facility Certification Form [PDF – 645 KB]
(OMB 0920-0020) (CDC/NIOSH 2.11) (March 2021)
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 Form [PDF – 933 KB]
(OMB 0920-0020) (CDC/NIOSH 2.14) (March 2021)
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 Document [PDF – 245 KB]
(OMB 0920-0020) (CDC/NIOSH 2.12) (March 2021)
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 – 2 MB]
En Español
(OMB 0920-0020) (CDC/NIOSH 2.9) (August 2022)
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 Form [PDF – 824 KB] (For official government use only)
(OMB 0920-0020) (CDC/NIOSH 2.8) (March 2021)
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 Form (July 2020)
The general purpose form is provided as a convenience to certified B Readers and is not an official government form.

Spirometry Results Notification Form [PDF – 225 KB] (March 2021)

Respiratory Assessment Form [PDF – 224 KB] (March 2021)