CDC/NIOSH (M) 2.12 Facility Certification Document

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

STATUS FOR NIOSH USE ONLY

INTERPRETING PHYSICIAN CERTIFICATION DOCUMENT
MEDICAL LICENSE NUMBER

NIOSH
RETURN
TO

Coal Workers' Health Surveillance Program
PO BOX 458
MORGANTOWN, WEST VIRGINIA 26504

STATE LICENSED IN
SOCIAL SECURITY NUMBER

NAME (LAST-FIRST-MIDDLE)

STREET ADDRESS

HOSPITAL OR DEPARTMENT
CITY

STATE

TELEPHONE NUMBER

SPECIALTY:

DATE OF BIRTH

ZIP CODE

During last year, monthly average
number of Chest films interpreted per
month

Primary

Chest films interpreted for
pneumoconioses per month

Board Certified?

Secondary

Chest films interpreted for other
occupational respiratory disease per
month

Primary

Yes

No

Secondary

Yes

No

I am applying to be a first or "A" reader, and
I choose to submit six ILO-U/C classified films for review
I have taken instruction in the ILO-U/C classification system
on

I attended the approved course at:
city

date

I am applying to be a first or "B" reader, and
I have taken the "B" Reader Proficiency exam at:

on

city

date
on

I have taken the "B" Reader Recertification exam at:
city

date

Do you anticipate that you will use this certification to interpret radiographs for occupational lung disease for:
Individual patient care
Government programs
Other

Industry programs

Medical-legal activities
Would you be interested in participating as a B Reader for the National Coal Workers' Xray Surveillance Program?
Yes

No

I agree that my participation in the X-Ray Surveillance Program for Underground Coal Miners will be conducted in the manner specified by Part 37, Title
42 of the Code of Federal Regulations, and understand that all information related X-Ray Interpretations made in connection with this Program will be
held STRICTLY CONFIDENTIAL and divulged only as specified by the above Regulation.

DATE

PHYSICIAN SIGNATURE
*Social Security Number is furnished solely for purpose of identification and reimbursement.
It will be treated as confidential information and released only with permission of the provider.

FOR ALOSH USE ONLY
CERT DATE
DATE OF EXAM

TYPE OF EXAM

B

SCORE

STUDY METHOD

A

R

B

EXAM SITE

C

D

CDC/NIOSH (M) 2.12(E), 07/2007, CDC Adobe Acrobat 5.0 Electronic Version, 3/2005
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or
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regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance
Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0020). Do not send the completed form to this address.

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