0920-0020 Medical Records Request Form - revised 15JUL2025

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS
H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-0020).
Form Approved OMB No. 0920-0020

NIOSH Coal Workers' Health
Surveillance Program
(CWHSP)

Request for Medical Records

Please provide answers to all the bulleted information below and mail or email to:
National Institute for Occupational Safety and Health
Coal Workers’ Health Surveillance Program
Mailstop LB208
1000 Frederick Lane
Morgantown, WV 26508
Email: CWHSP@cdc.gov
•

Today’s date

•

I request a copy of my:

Chest Radiograph (x-ray) dated
Radiograph Interpretation Sheets
•

Send my medical records to:

My home
My Personal Physician
Other
•

Address where medical records should be sent:
Name
Street
City
State
Phone # (
)

Zip

•

The last 4 digits of my social security number are:

•

My birthdate is:

•

If you need to contact me for clarifications on this request, I can be reached at:

Home Phone # (
Work Phone # (
•

)
)

“I hereby certify that I am

(print your name here)

and understand that

knowing and willful request for, or acquisition of, records pertaining to an individual under false
pretenses is a criminal offense under the Privacy Act, subject to a $5,000 fine.”
•

Signature

(Required before NIOSH can send copies of medical records.)

@NIOSHBreathe  https://www.cdc.gov/niosh/cwhsp/about/index.html  NIOSH Facebook  1-800-480-4042