13. Exertional requirements of the most recent coal mine job.

8. Job Title Most Recent Coal Mine Employment:

7. Your Telephone Number:

4. Your Mailing Address (Number, Street, Apt. No., PO Box): 5. City, State, and Zip Code:

1. Miner's Name (First, Middle, Last): 2. Miner’s Social Security Number: 3. DOL’s Case ID Number:

U.S. DEPARTMENT OF LABOR 

Office Of Workers' Compensation Programs 

Division Of Coal Mine Workers' Compensation 

Employment History

Please provide as accurately as possible the miner's COMPLETE coal mine employment history. This report is authorized by law 

(30 U.S.C. 901 et. seq.) and required to obtain a benefit. While you are not required to respond, your cooperation is needed to 

ensure that full and proper consideration is given to this claim. Disclosure of the social security number is voluntary. Failure to 

disclose such number will not result in the denial of any right, privilege, or benefit to which you may be entitled.

OMB No. 1240-0038 

Expires: 10/31/2026

CM-911a (Rev. 10/2023)

6. Your Email Address:

PART I - DESCRIPTION OF MOST RECENT COAL MINE WORK

9. Dates Worked (mm/dd/yyyy):

From: To:

10. Name of Most Recent Coal Mine Operator:

a. State of Most Recent Coal Mine Employment:

11. Number of days worked per week:

a. Hourly Pay rate:

b. Hours worked per day:

c. Approximate Annual Earnings:

12. Where was your/the miner’s work location? 

Coal Preparation Facility Coal Mine-Underground Mine Coal Mine-Surface Mine Other

a. What type of Coal Mine work was being performed?

Extraction Preparation Transportation Maintenance Construction Other If other, please explain:

b. Were you/the miner exposed to dust, gases, or fumes? Yes No If yes, please indicate how often, how long, and how much exposure. 

c. Please describe your/the miner’s most recent Coal Mine Employment duties.

d. Where was the work being done? (Examples: in the shaft, at the face, tipple, warehouse, etc.)

e. What type of mining equipment did you/the miner use? (Continuous miner, longwall, dozer, haulage driver truck, etc.)

f. Why did your/the miner’s Coal Mine Employment end?

Never Less than 1 hour 1-4 hours per day 4-8 hours per day More than 8 hours per day How many hours a day did 

you/the miner sit down?

Never Less than 1 hour 1-4 hours per day 4-8 hours per day More than 8 hours per day How many hours a day did 

you/the miner stand up?

Never Less than 1 hour 1-4 hours per day 4-8 hours per day More than 8 hours per day How many hours a day did 

you/the miner crawl?

Less than 10 pounds 10-25 pounds 26-50 pounds More than 50 pounds How heavy were the items 

you/the miner had to lift?

How often did you/the miner 

lift those items?

Less than 10 pounds 10-25 pounds 26-50 pounds More than 50 pounds How heavy were the items 

you/the miner had to carry?

How far and how often did 

you/the miner carry those 

items?
17. Type of Coal 

Mine Work

15. Period of 

Employment 

(mm/dd/yyyy)

16. Location of Work 18. Occupation 

and Job Duties

14. Name of Employer, 

City and State of 

Employment Site 

Part II - OTHER COAL MINE WORK 

List all Coal Mine Employment. Start with the next most recent position. 

19. Exposure to 

dust, gases, or 

fumes?

Name

City

State

Start Date:

End Date:

Occupation: No

Yes

Coal Preparation Facility

Coal Mine- Underground

Coal Mine- Surface

Other location

If other location, please 

explain:

Extraction

Preparation

Transportation

Maintenance 

Construction

Other

If other, please explain:

Job Duties: If yes, please 

indicate how often, 

how long, and how 

much exposure:

Page 2 CM-911a (Rev. 10/2023)

Name

City

State

Start Date:

End Date:

Occupation: No

Yes

Coal Preparation Facility

Coal Mine- Underground

Coal Mine- Surface

Other location

If other location, please 

explain:

Extraction

Preparation

Transportation

Maintenance 

Construction

Other

If other, please explain:

Job Duties: If yes, please 

indicate how often, 

how long, and how 

much exposure:

Name

City

State

Start Date:

End Date:

Occupation: No

Yes

Coal Preparation Facility

Coal Mine- Underground

Coal Mine- Surface

Other location

If other location, please 

explain:

Extraction

Preparation

Transportation

Maintenance 

Construction

Other

If other, please explain:

Job Duties: If yes, please 

indicate how often, 

how long, and how 

much exposure:

Name

City

State

Start Date:

End Date:

Occupation: No

Yes

Coal Preparation Facility

Coal Mine- Underground

Coal Mine- Surface

Other location

If other location, please 

explain:

Extraction

Preparation

Transportation

Maintenance 

Construction

Other

If other, please explain:

Job Duties: If yes, please 

indicate how often, 

how long, and how 

much exposure:

Name

City

State

Start Date:

End Date:

Occupation: No

Yes

Coal Preparation Facility

Coal Mine- Underground

Coal Mine- Surface

Other location

If other location, please 

explain:

Extraction

Preparation

Transportation

Maintenance 

Construction

Other

If other, please explain:

Job Duties: If yes, please 

indicate how often, 

how long, and how 

much exposure:

Name

City

State

Start Date:

End Date:

Occupation: No

Yes

Coal Preparation Facility

Coal Mine- Underground

Coal Mine- Surface

Other location

If other location, please 

explain:

Extraction

Preparation

Transportation

Maintenance 

Construction

Other

If other, please explain:

Job Duties: If yes, please 

indicate how often, 

how long, and how 

much exposure:
Page 3 CM-911a (Rev. 10/2023)

Name

City

State

Start Date:

End Date:

Occupation: No

Yes

Coal Preparation Facility

Coal Mine- Underground

Coal Mine- Surface

Other location

If other location, please 

explain:

Extraction

Preparation

Transportation

Maintenance 

Construction

Other

If other, please explain:

Job Duties: If yes, please 

indicate how often, 

how long, and how 

much exposure:

Name

City

State

Start Date:

End Date:

Occupation: No

Yes

Coal Preparation Facility

Coal Mine- Underground

Coal Mine- Surface

Other location

If other location, please 

explain:

Extraction

Preparation

Transportation

Maintenance 

Construction

Other

If other, please explain:

Job Duties: If yes, please 

indicate how often, 

how long, and how 

much exposure:

PART III: ADDITIONAL COAL MINE WORK INFORMATION 

Please note that your entitlement to benefits will in no way be impacted by your responses in this Part.

20. While working as a coal miner, did you/the miner ever use personal protective equipment? Yes No

a. If yes, please provide additional details. What personal protective equipment did you/the miner use? How often did you/the miner utilize the 

equipment?

b. Do you/the miner believe the personal protective equipment prevented breathing coal mine dust? Please explain:

21. Were you/the miner ever transferred from a previous job due to health reasons? (Example: Did you/the miner ever receive a 90 Miner Status from Mine 

Safety and Health Administration?) Yes No

a. If yes, what was the date of transfer? b. What was the reason of transfer? 

PART IV: OTHER RELEVANT INFORMATION

22. Have you/the miner been exposed to dust, gases, or fumes during any employment outside of coal mine employment? If so, what was your/the miner’s 

occupation, job duties, and length of employment where the exposures took place? How often (frequency), how long (duration), and how much (extent) 

were your/the miner’s exposures?

23. Did you/the miner ever have any hobbies or interests where you/the miner have been exposed to dust, gases, or fumes? If so, please describe.

24. Use this section for additional space to answer any previous question, or to provide any other information you feel would be helpful. Please refer to 

previous questions by the corresponding number. If more space is needed, use a blank sheet and attach.
Page 4 CM-911a (Rev. 10/2023)

TWO FILING OPTIONS: 

1. To file electronically, submit completed form and accompanying documentation to the C.O.A.L. Mine Portal: 

https://coalmine.dol.gov

2. To file by mail, submit completed form and accompanying documentation to: 

U.S. Department of Labor OWCP/DCMWC 

Central Mail Room 

PO Box 8307 

London, KY 40742-8307 

For further information call TOLL FREE: 1-800-347-2502

PRIVACY ACT NOTICE 

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) the Black Lung Benefits Act (BLBA) (30 U.S.C. 

901 et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives and 

maintains personal information, relative to this application, on claimants and their immediate families; (2) information obtained by OWCP will be used to 

determine eligibility for benefits payable under the BLBA; (3) information may be given to other government agencies, coal mine operators potentially liable 

for payment of the claim or to the insurance carrier or other entity which secured the operator's compensation liability, contractors providing automated data 

processing services to the Department of Labor; and representatives of the parties to the claim; (4) infrmation may be given to physicians or other medical 

service providers for use in providing treatment, making evaluations and for other purposes relating to the medical management of the claim; (5) 

informationmay be given to the Department of Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or 

required to render decisions with respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or 

local agencies for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have 

been paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law; (7) disclosure of the 

claimant's or deceased miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary, and the SSN and/or TIN and other 

information maintained by the OWCP may be used for identification and for other purposes authorized by law; (8) failure to disclose all requested 

information, may delay the processing of this claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits; and (9) 

this information is included in a System of Records, DOL/OWCP-2 published at 81 Federal Register 25765, 25858 (April 29, 2016) or as updated and 

republished.

PUBLIC BURDEN STATEMENT 

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions, searching 

existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this 

burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division 

of Coal Mine Workers’ Compensation, Room C-3520, 200 Constitution Avenue, N. W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM 

TO THIS OFFICE. 

Notice 

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in 

the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of 

documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the 

limitations of your disability. Please contact our office or the claims examiner to ask for assistance. 

I hereby certify that the information given by me on and in connection with this form is true and correct to the best of my knowledge and belief. I am also fully 

aware that any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or payment under this 

title shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, subject to a fine of not more than 

$1,000, or by imprisonment for not more than one year, or both.

25. Signature of claimant (First, middle, last)

Witnesses are required only if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know 

the applicant must sign below, giving their full address.

27. Signature of witness 28. Signature of witness

NOTE: Persons are not required to respond to this collection of information unless it displays currently valid OMB control Number.

26. Date (Month, day, year)

29. Address (Number, Street, City, State & Zip Code) 30. Address (Number, Street, City, State & Zip Code)