9 Coal Workers' Health Surveillance Program (CWHSP)- Repor

ATTACHMENT 11

NCWAS Autopsy Checklist

NATIONAL COAL WORKERS= AUTOPSY STUDY (NCWAS)

Checklist

The following items must be complete to insure payment for services and for the autopsy to be included in the NCWAS database.

_______ Death must have occurred on or after May 14, 1971.

_______ Case must be received within 180 days of autopsy.

_______ Deceased must have worked in an underground mine.

_______ Must include the following articles:

_______ 3 blocks of lung tissue

_______ 3 stained slides of lung tissue

_______ completed and signed Consent, Release, and History

Form (CDC/NIOSH 2.6)

_______ Social Security Number (optional)

_______ Signed invoice with statement ANo other form of compensation

has been received.@

_______ Autopsy protocol must include:

_______ heart and lung description and weights

_______ heart valve measurements

_______ heart ventricular measurements

_______ pathological diagnosis

_______ cause of death (optional on partial autopsies)

_______ clinical summary

_______ microscopic examination

_______ age, height, and weight

_______ Chest x-ray (PA) and interpretation made within 5 years

prior to death (optional)