Form CM-913 

Rev. Oct. 2023

U. S. Department of Labor 

Office of Workers' Compensation Programs

Division of Coal Mine Workers' Compensation

Description of Coal Mine Work 

and Other Employment

OMB No. 1240-0035 

Expires: 10/31/2026 This report is authorized by the Black Lung Benefits Act (30 USC 901 et seq.).

PART I - DESCRIPTION OF MOST RECENT COAL MINE WORK

Miner's Name (Last, First, Middle Initial) Miner's Last Four Digits of Social Security 

Number or DOL's Case ID Number

1. Job Title

From: To:

2. Dates Worked (mm/dd/yyyy)

3. Highest or current rate of pay 4. Number of days worked per week

5. Please provide the following information for the MOST RECENT COAL MINE EMPLOYMENT. If you are still working in coal mine 

employment, describe your current position.

5a. What is the name of the coal mine operator and the state where you/the miner most recently worked?

5b. While working as a coal miner, did you/the miner ever use personal protective equipment? If yes, please explain if and how it prevented 

breathing coal mine dust.

FOR UNDERGROUND WORK

5c. How did you/the miner approach the coal seam?

tunneling slope a shaft a drift mine other

5d. What was the height of the coal seam? 

5e. Where was the work being done? (examples: in the shaft, at the face) 

5f. What type of mining equipment did you/the miner use? (examples: continuous miner, conventional mining, longwall) 

FOR SURFACE WORK

5g. Where was the work being done? (examples: tipple, warehouse)

5h. What type of mining equipment did you/the miner use? (examples: dozer operator, haulage truck driver)

6. Describe the exertional requirements of the most recent coal mine job.

Sitting for hours per day.

Standing for hours per day.

Crawling (distance) for hours per day.

Lifting pounds times per day.

Lifting pounds times per day.

(example: 25 pounds 10 times per day).

Lifting pounds times per day.

Carrying pounds (distance) times per day. 

(example: 20 pounds 50 feet 15 times per day)

Carrying pounds (distance) times per day. 

Carrying pounds (distance) times per day. 
Form CM-913 

Rev. Oct. 2023

7. Did the most recent coal mine job involve:

a. The use of tools, machines or equipment:? Yes No

b. Were you/the miner exposed to dust or fumes? Yes No

c. Technical knowledge or special skills? Yes No

d. Any supervisory responsibilities? Yes No

Please explain all "YES" answers. For example, state the specific type of tools, machines or equipment you/the miner used; what type 

of dust, fumes or gas you/the miner were exposed to during the operation of tools, machines or equipment (examples: rock dust, gas or 

diesel fumes); the nature of any technical knowledge or special skills you/the miner needed; and the nature of any supervisory duties, 

including the number and type of employees you/the miner supervised, the extent to which they had to be supervised, etc.

8. 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?) 

 If "YES", provide a copy and the following information:

e. If coal mine work has stopped, give reason and last date worked:

a. Previous Job b. Job Transferred To

c. Effective date of transfer: d. Reason

Job Title

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

Dates Worked

Part II - OTHER COAL MINE WORK

9. List all other coal mine jobs you/the miner worked for at least one year. 
Form CM-913 

Rev. Oct. 2023

PART III: DESCRIPTION OF MOST RECENT NON-COAL MINE EMPLOYMENT 

DESCRIBE MOST RECENT NON-COAL MINE EMPLOYMENT

10. Job Title 11. Type of business or industry

From: To:

12. Dates Worked 13. Highest or current rate of pay 14. Number of days worked per week

 15. Describe the duties of this job in your own words:

16. Describe the exertional requirements required by the NON-COAL MINE job.

Sitting for hours per day.

Standing for hours per day.

Lifting pounds times per day.

Lifting pounds times per day.

(example: 25 pounds 10 times per day).

Lifting pounds times per day.

Carrying pounds (distance) times per day. 

(example: 20 pounds 50 feet 15 times per day)

Carrying pounds (distance) times per day. 

Carrying pounds (distance) times per day. 

17. Did the NON-COAL MINE job involve: 

a. The use of tools, machines or equipment:? Yes No

b. Were you exposed to dust or fumes? Yes No

c. Technical knowledge or special skills? Yes No

d. Any supervisory responsibilities? Yes No

Please explain all "YES" answers. For example, state the specific type of tools, machines or equipment you/the miner used; what type 

of dust, fumes or gas were you/the miner exposed to during the operation of tools, machines or equipment (examples: construction 

dusts, gas or diesel fumes); the nature of any technical knowledge or special skills you/the miner needed; and the nature of any 

supervisory duties, including the number and type of employees you/the miner supervised, the extent to which they had to be 

supervised, etc. 

18. If NON-COAL MINE work has stopped, give reason and last date worked: 
Form CM-913 

Rev. Oct. 2023

PART - IV 

19. 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.

I 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.

Signature of claimant or person filing on his/her behalf:

Public Burden Statement 

Public reporting burden for this collection of information is estimated to average 30 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-3526, 200 Constitution Avenue, N.W., Washington, D.C. 20210. 

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. 

NOTE: Persons are not required to respond to this collection of information unless it displays a current valid OMB control number. 

Privacy Act Statement 

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) 

information 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) information may 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. 

 

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 about this assistance.

Date: