Form Individual Exposur Individual Exposur 4000-9

Record of Individual Exposure
to Radon Daughters

U.S. Department of Labor
Mine Safety and Health Administration

Form Approved: O.M.B. No. 1219-0003, Approval Expires May 31, 2017.
The operator shall calculate and record complete individual exposures to concentrations of radon daughters. 30 CFR 57.5040(b) requires
the operator to maintain MSHA Form 4000-9, or an equivalent form acceptable to the Administrator of Metal and Nonmetal Mine Safety
and Health. Data submitted to MSHA (on MSHA Form 4000-9, Record of Individual Exposure to Radon Daughters) is intended to: (a)
Establish a means by which MSHA can assure compliance with underground radiation standards; (b) form a data base of miner exposure for future epidemiological studies; and (c) assure that miners can, upon written request, have records of cumulative exposures
made available to them or their state, and to medical and legal representatives who have obtained written authorization.
Responding to this report is mandatory for a mine operator (30 CFR, Part 57). Failure to report can result in assessment of a civil penalty
under Section 110 and institution of a civil action for relief under Section 108 of the Federal mine Safety and Health Act 1977. Knowingly
making a false statement or concealing a material fact can result in criminal prosecution under Section 110 of the Federal Mine Safety and
Health Act of 1977 and 18 U.S.C. 1001.
This form is affected by the Privacy Act of 1974
Public reporting burden for this collection of information is estimated to average 1.50 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the date need, and completing and reviewing the collection of
information. Send comments regarding the collection of information, including suggestions for reducing this burden, to the Mine Safety
and Health Administration, U.S. Department of Labor, Office of Standards, Regulations and Variances, 201 12th Street South, Suite 401,
Arlington, Virginia 22202-5452. Persons are not required to respond to this collection of information unless it displays a currently valid
Control Number.

1.

Mine ID Number

2.

Mine

3.

Section

4.

Township

5.

Range

6.

County

7.

State

8.

Operator

9.

Period ___/___/20___

10.

Individual Exposure to Radon Daughters

Identification Number
Name

MSHA Form 4000-9, Aug. 2015 rev. (Mailing Address)

Exposure, WLM
Current Year

Cumulative Total