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 -XQH , 201. 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. This report is required by law (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 1.5 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, Records Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 222093939. 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 Exposure, WLM Identification Number Name Current Year Cumulative Total American LegalNet, Inc. www.FormsWorkFlow.com MSHA Form 4000-9, )HEUXDU\ 20 (Revised)