Roentgenographic Quality Rereading

U.S. Department of Labor

Roentgenographic Quality Rereading

Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation
NOTE: This report is authorized by law (30 U.S.C., 901 et. seq. and 20 CFR 718.102) and required to obtain a benefit. The
results of this interpretation will aid in determining the miner's eligibility for black lung benefits. Disclosure of a social
security number is voluntary. The failure to disclose such number will not result in the denial of any right benefit, or
privilege to which the claimant may be entitled. This method of collecting information complies with the Freedom of
information Act, the Privacy Act of 1974, and OMB Cir. No. 108.

OMB No. 1215-0090
Expires: 07-31-2008

Please record your quality finding of a single film by placing ''X" in the appropriate boxes on the form and return it promptly to the office that
requested the interpretation. The form must be completed as per instructions, signed by a physician, and contain the miner's name, and
social security number. The Department of Labor will pay only for films of acceptable quality (1, 2 and 3). Films of inferior quality (U/R) must
be retaken without cost to the Department.
1A. Miner's Name (Print)

1C. Miner's Social Security Number

1B. Date of X-ray

Mo.

1D. Film Quality (If not Grade
1. Give Reason):
1

YR.

DAY

2A. ANY OTHER ABNORMALITIES ?
YES

Complete
2B and 2C

2

3

U/R

Proceed to
Section 3

NO

2B. OTHER SYMBOLS (OBLIGATORY)

aa
aa atO axax bubuca cacg cncn co
co cp
cp
REPORT ITEMS WHICH
MAY BE OF PRESENT
CLINICAL SIGNIFICANCE
IN THIS SECTION.

cv

di
di

ef em
em eses fr fr hi hi ho hoid idih ihkl
ef

ki
pl
me
pa

px
pb

rp pxtb ra
pi

rp

tb

Date Personal Physician notified?

(Specify od.)

Mo.

OD

Day

Yr.

2C. OTHER COMMENTS
2D. SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 2C?
Yes
3A. FACILITY PROVIDING ROENTGENOGRAPHIC EXAMINATION:
DOL Medical Provider Number (If applicable):
Was film taken by a registered radiographer/radiographic technologist?
Name

Yes

Proceed to Section 3

No

No

State

Registration No.

3B. Physician Interpreting Film (Print Name):
Are you: Board-certified Radiologist?

Yes

No

Board-eligible radiologist?

Yes

No

B-reader?

Yes

No

3C. I certify that this film has been re-read for quality in accordance with the instructions provided by 20 CFR 718, Subpart B, 718.102 and
Appendix A. I also certify that the information furnished is correct and am aware that my signature attests to the accuracy of the results reported.
I am aware that any person who willfully makes any false or misleading statements or representation in support of an application for benefits
under Title 30 USC 941 shall be guilty of a misdemeanor and subject to a fine of up to $1,000, or to imprisonment for up to one-year, or both.

PHYSICIAN'S SIGNATURE

DATE OF RE-READING
(Mo., Day, Yr.)

Public Burden Statement
We estimate that it will take an average of 3 minutes to complete this information collection, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have
any comments regarding these estimates or any other aspect of this survey, including suggestions for reducing this burden, send them to
the Division of Coal Mine Workers' Compensation, U.S. Department of Labor, Room N-3464, 200 Constitution Avenue, N.W., Washington,
D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

Form CM-933b
Rev. Sept. 2001

For Purposes of Coding for the Department of Labor, the following criteria will be used

ILO 1980 INTERNATIONAL CLASSIFICATION OF RADIOGRAPHS OF THE PNEUMOCONIOSES

1D

Technical Quality
DEFINITIONS

CODES

- Good
- Acceptable, with no technical defect likely to impair classification of

1

2

the radiograph for pneumoconiosis.
- Poor, with some technical defect but still acceptable for classification
purposes.
- Unacceptable.

3
U/R

Other Symbols

2B

It is to be taken that the definition of such Symbols is preceded by an appropriate word or phrase such as "suspect" or
"suggestive of", etc.
DEFINITIONS

SYMBOLS

2C

2C

aa
ax
at
bu
ax
ca
bu
cn
ca
co
cg
cp
cn
cv
co
di
cp
ef
cv
em
di
es
ef
fr
em
hi
ho
es
id
fr
ih
hi
kl
ho
od
id
pl
ih
px
kl
rp
me
tb
pa
pb
pi
px
ra
rp
tb
od

-

atherosclerotic aorta
- coalescence
smallthickening
pneumoconlotic opacities.
significant
apicalof
pleural
- bulla (e) of small pneumoconiotic opacities
coalescence
- cancer of lung or pleura
bulla(e)
- calcification in small pneumoconiotic opacities
cancer
of lung or pleura
abnormality
of cardiac size nodules
or shape
calcified
non-pneumococoniotic
cor pulmonale
calcification in small pneumococoniotic opacities
- cavity
abnormality
of cardiac size
or shape
- marked distortion
of the
intrathoracic organs
cor
pulmonale
- effusion
cavity
- definite emphysema
marked
distortion
of the intrathoracic
organs
- eggshell
calcification
of hilar or mediastinal
lumph nodes
- fractured rib(s)
effusion
definite
emphysema
enlargement
of hilar or mediastinal lumph nodes
honeycomb
lung of hilar or mediastinal lymph nodes
eggshell
calcification
- ill defined
diaphragm
fractured
rib(s)
(acute or healed)
- ill definedof
heart
enlargement
hilar outline
or mediastinal lymph nodes
- septal (kerley)
honeycomb
lung lines
- other significant abnormality
ill defined diaphragm
- pleural thickening in the interiobar fissure or mediastinum
ill
defined heart outline
- pneumothorax
septal
(kerley) lines
- rheumatoid
pneumoconiosis
mesothelioma
tuberculosis
plate atelactasis
parencymal bands
pleural thickening of an interiobar fissue
pneumothorax
rounded atelectasis
rheumatoid pneumoconiosis
tuberculosis
other significant abnormality

Comments

If comments are present, please check the "Yes" or "No" box to indicated if the miner should see personal physician.