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Form number: MSHA Form 4000-9
Form name: Record of Individual Exposure to Radon Daughters
Description: Operators are required to maintain accurate records of employee exposures to potentially toxic materials or harmful physical agents. Data submitted to MSHA on Form 4000-9 establishes a means by which MSHA can: assure compliance with underground radiation standards; form a database for epidemiological studies; and provide information of cumulative radon exposures.
OMB Control Number and
Expiration Date:
1219-0003; 06/30/2014
Filing Options: Form 4000-9 can be filled in on line and emailed or printed out and sent to MSHA according to the instructions provided below.

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Filing Instructions: 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. Specific information required by the form with respect to each person's time-weighted current and accumulative exposure to concentrations for radon daughters shall be recorded. Each form shall be available for examination by the Secretary or his authorized representative. On or before February 15 of each calendar year, or within 45 days after the shutdown of mining operations for the calendar year, each mine operator shall submit to the Mine Safety and Health Administration a copy of the "Record of Individual Exposure to Radon Daughters" (Form 4000-9), or acceptable equivalent form, showing the data required by the form for all personnel for whom calculation and recording of exposure was required during the previous calendar year. The operator's records of individual exposure to concentrations of radon daughters and copies of "Record of Individual Exposure to Radon Daughters" (Form 4000-9) or acceptable equivalent form or true legible facsimiles thereof (microfilm or other), shall be retained at the mine or nearest mine office for a period as specified in paragraph 9.8, ANSI N13.8-1973, or shall be submitted to the Mine Safety and Health Administration. These records, if retained by the operator, shall be open for inspection by the Secretary of Labor, his authorized representative, and authorized representatives of the official mine inspection agency of the State in which the mine is located.
Chief, Division of Health
Metal and Nonmetal Mine Safety and Health
Mine Safety and Health Administration
Room 2406
1100 Wilson Boulevard
Arlington, Virginia 22209-3939

If questions arise, the nearest MSHA office may be contacted for clarification. Detailed instructions for filing Form 4000-9 are available using this link.

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 of 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.

Contact Information: Questions regarding this form should be directed to MSHA at
(877) 778-6055 or MSHAhelpdesk@dol.gov
Privacy Notice: Privacy Notice
Legal Authority: 30 CFR 57.5040(b)
Burden Statement: This form is affected by the Privacy Act of 1974
Public reporting burden for this collection of information is estimated to average 8 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number.

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