Form CDC/NIOSH (M) 2.8 CDC/NIOSH (M) 2.8 Roentgenographic Interpretation

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE

1544192534
DATE OF RADIOGRAPH
MONTH

DAY

OMB No.: 0920-0020

CENTERS FOR DISEASE CONTROL & PREVENTION
National Institute for Occupational Safety and Health
Federal Mine Safety and Health Act of 1977
Medical Examination Program

YEAR

WORKER'S Social Security Number

Coal Workers' Health Surveillance Program
NIOSH
PO Box 4258
Morgantown, West Virginia 26504

ROENTGENOGRAPHIC INTERPRETATION
TYPE OF READING

Note: Please record your interpretation of a single film by
placing an "x" in the appropriate boxes on this form.
1.

FILM QUALITY
1

2

3

U/R

(If not Grade 1, mark all
boxes that apply)

Underinflation

Underexposed (light)

Poor contrast

Mottle

Artifacts

Poor processing

Other (please specify)

2B.

SMALL OPACITIES

R
UPPER

1/0 1/1 1/2
2/1 2/2 2/3
3/2 3/3 3/+

q

t

q

t

r

u

r

u

LOWER

2C.

c. PROFUSION

3B.

PLEURAL PLAQUES
Site

Chest wall

O

R

Face on

O

R

Diaphragm

O

R

L

O

R

L

O

R

Other site(s)

O

R

L

O

R

L

1

2

R

L

3C.

COSTOPHRENIC ANGLE OBLITERATION

3D.

DIFFUSE PLEURAL THICKENING (mark site, calcification,

3

Calcification

In profile

O

R

L

O

R

L

O

R

Face on

O

R

L

O

R

L

1

2

4B.

OTHER SYMBOLS (OBLIGATORY)
aa at ax bu ca cg cn co cp

1

2

3

O

R

a

b

di

ef

em

es

fr

O

L

a

b

c

c
Proceed to
Section 4A

Width (in profile only)
(3mm minimum width required)
3 to 5 mm = a
5 to 10 mm = b
> 10 mm = c

O

L

1

2

3

3

hi

ho

id

ih

kl

O

R

a

b

me

pa

pb

L

a

b

pi

px

c
Proceed to
Section 5

NO

ra

rp

tb

Date Physician or Worker notified?

If other diseases or significant abnormalities, findings must be recorded on reverse. (section 4C/4D)

Should worker see personal physician because of findings in section 4? YES

O
c

Complete Sections
4B, 4C, 4D, 4E

MONTH

4E.

Proceed to
Section 4A

NO

NO

YES

cv

Proceed to
Section 3A

C

Width (in profile only)
(3mm minimum width required)
3 to 5 mm = a
5 to 10 mm = b
> 10 mm = c

Extent (chest wall; combined for
in profile and face on)
Up to 1/4 of lateral chest wall = 1
1/4 to 1/2 of lateral chest wall = 2
> 1/2 of lateral chest wall = 3

extent, and width)

ANY OTHER ABNORMALITIES?

L

B

Proceed to
Section 3D

Site

4A.

O

A

Complete Sections
3B, 3C

(mark site, calcification, extent, and width)
Calcification
Extent (chest wall; combined for
in profile and face on)
L
O R L
Up to 1/4 of lateral chest wall = 1
1/4 to 1/2 of lateral chest wall = 2
L
O R L
> 1/2 of lateral chest wall = 3

Chest wall

O

YES

In profile

OD

LARGE OPACITIES

SIZE

ANY PLEURAL ABNORMALITIES
CONSISTENT WITH PNEUMOCONIOSIS?

3A.

Proceed to
Section 3A

NO

0/- 0/0 0/1

L

s

MIDDLE

Complete Sections
2B and 2C

YES
b. ZONES

a. SHAPE/SIZE
PRIMARY
SECONDARY

p

P

Improper position

ANY PARENCHYMAL ABNORMALITIES
CONSISTENT WITH PNEUMOCONIOSIS?

s

B

Overexposed (dark)

2A.

p

A

FACILITY IDENTIFICATION

DAY

YEAR

NO

Proceed to Section 5

PHYSICIAN'S Social Security Number*

5.

* Furnishing your social security
number is voluntary. Your refusal
to provide this number will not
affect your right to participate in
this program.

FILM READER'S
INITIALS

DATE OF READING
MONTH

DAY

YEAR

LAST NAME - STREET ADDRESS

CITY

STATE

CDC/NIOSH (M) 2.8
REV. 7/2007

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ZIP CODE

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4961192530
4C. MARK ALL BOXES THAT APPLY: (Use of this list is intended to reduce handwritten comments and is optional)
Abnormalities of the Diaphragm

Lung Parenchymal Abnormalities

Eventration

Azygos lobe

Hiatal hernia

Density, lung
Infiltrate
Nodule, nodular lesion

Airway Disorders
Bronchovascular markings, heavy or increased
Hyperinflation

Miscellaneous Abnormalities
Foreign body
Post-surgical changes/sternal wire

Bony Abnormalities
Bony chest cage abnormality

Cyst

Fracture, healed (non-rib)
Fracture, not healed (non-rib)

Vascular Disorders

Scoliosis

Aorta, anomaly of

Vertebral column abnormality

Vascular abnormality

4D. OTHER COMMENTS

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