Program Forms

B Readers

• B Reader Scheduling Form

Complete this form if you are a physician interested in taking the NIOSH B Reader exam. Email the completed form and a copy of your current medical license to cwhsp@cdc.gov. You will receive a confirmation email with your exam date and additional information.

• Chest Radiograph Classification Form (For official government use only.)

This form must be completed by B Readers that interpret chest radiographs for the CWHSP. Email completed forms to cwhsp@cdc.gov.

• General Purpose Chest Radiograph Classification Form

This is a general classification form intended to be used by certified B Readers. It is not an official government form.

Coal miners

• Miner Identification Form (En Español)

Miners must fully complete, sign, and provide this form to their health facility during screening appointments. Print/Copy as a double-sided form. The completed form, along with the miner's chest x-ray, will then be submitted to the CWHSP.

• Request for Medical Records Form

Miners wishing to receive copies of their CWHSP chest x-rays and related files must fully complete, sign, and email the form to cwhsp@cdc.gov. The form can also be mailed or faxed using the address and fax listed on the form.

Mine operators and contractors

• Coal Mine Operator Plan

Coal mine operators should use this form when submitting plans for their miners to receive chest x-rays at designated x-ray facilities. Plans and Part 48 trained employee rosters must be submitted to the CWHSP that include names and home addresses:

No later than 60 days after opening a new mine

OR

Within 30 days when mine ownership is transferred.

Email completed forms to cwhsp@cdc.gov. If unable to email, send by mail using the address listed on the form.

• Coal Mine Contractor Plan

Contractors should use this form when submitting a mine plan for their employees to receive chest x-rays at designated x-ray facilities. Plans and Part 48 trained employee rosters must be submitted to the CWHSP that include names and home addresses:

No later than 60 days after opening a new mine

OR

Within 30 days when mine ownership is transferred.

Email completed forms to cwhsp@cdc.gov. If unable to email, send by mail using the address listed on the form.

Spirometry facilities

• Spirometry Facility Certification Form

Complete this request form to become a NIOSH-approved spirometry facility. Email completed forms to cwhsp@cdc.gov. If unable to email, send the form by mail using the address listed on the form.

• Spirometry Results Notification Form

This form must be completed by NIOSH-approved spirometry facilities prior to each spirometry test session and emailed to cwhsp@cdc.gov. The form should be used to identify possible contraindications to testing or factors that might affect testing results.

• Respiratory Assessment Form

NIOSH-approved spirometry facilities must complete this form during initial spirometry tests and at each subsequent test. Email completed forms to cwhsp@cdc.gov.

Radiograph facilities

• Radiographic Facility Certification Form

Complete this form to become a NIOSH-approved radiograph facility. Email completed forms to cwhsp@cdc.gov. If unable to email, send the form by mail using the address listed on the form.