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View ESA-OWCP-DCMWC's Form 1215-0052 Online 
| Agency: |
ESA-OWCP-DCMWC |
| Title: |
CM-911a, Employment History |
| Form Description: |
CM-911a, Employment History: An applicant filing for black lung benefits must complete a CM 911a. This form is used to help determine if the miner worked in the Nation's coal mines, the extent of dust exposure, and who would potentially be liable for benefit payments. |
| OMB Control Number: |
1215-0052 |
| OMB Expiration Date: |
Friday, September 30, 2011
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