Agency:

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

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