Form No 2.8 Form No 2.8 rointgenographic interpretation form

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
DATE OF RADIOGRAPH

MONTH

0 1

DAY

YEAR

2 3

2 0 1 3

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

WORKER'S Social Security Number

1 1 1

1 1

1

2

3

U/R

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

Underexposed (light)

Poor contrast

Mottle

Artifacts

Poor processing

Other (please specify)

SMALL OPACITIES

t

r

u

R

c. PROFUSION

2C.

3B.

s

UPPER

1/0 1/1 1/2

q

t

MIDDLE

2/1 2/2 2/3

r

u

LOWER

3/2 3/3 3/+

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

4E.

L

1

2

di

ef

em

es

fr

Proceed to
Section 4A

NO

3

O

R

a

b

O

L

a

b

c

c
Proceed to
Section 4A

NO

O

L

1

2

3

hi

ho

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

3

id

ih

kl

O

R

a

b

pa

pb

L

a

b

c

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

me

O

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)
MONTH
DAY
YEAR
(See reverse for other symbol definitions.)

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

NO

Proceed to Section 5

PHYSICIAN'S Social Security Number*

5.

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

YES

cv

B

Complete Sections
3B, 3C

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?

O

A

Proceed to
Section 3D

Site

4A.

O

SIZE

YES

In profile

OD

LARGE OPACITIES

(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

Proceed to
Section 3A

NO

0/- 0/0 0/1

L

ANY PLEURAL ABNORMALITIES
CONSISTENT WITH PNEUMOCONIOSIS?

3A.

Complete Sections
2B and 2C

YES
b. ZONES

a. SHAPE/SIZE
PRIMARY
SECONDARY

q

1 2 3 4 5

F
Underinflation

2B.

p

B

Improper position

ANY PARENCHYMAL ABNORMALITIES
CONSISTENT WITH PNEUMOCONIOSIS?

s

A

Overexposed (dark)

2A.

p

FACILITY IDENTIFICATION

TYPE OF READING

1 1 1 1

FILM QUALITY

Coal Workers' Health Surveillance Program
NIOSH
1095 Willowdale Road M/S LB208
Morgantown, West Virginia 26505

ROENTGENOGRAPHIC INTERPRETATION

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

OMB No.: 0920-0020

* 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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4B. Other Symbol Definitions
Each of the following definition of symbols assumes an introductory qualifying word or phrase such as
"changes indicative of" or "opacities suggestive of", or "suspect."
aa
at
ax

bu
ca
cg
cn
co
cp
cv
di
ef
em

atherosclerotic aorta
significant apical pleural thickening
coalescence of small opacities - with margins of the small opacities
remaining visible, whereas a large opacity demonstrates a
homogeneous opaque appearance - may be recorded either in the
presence or in the absence of large opacities
bulla(e)
cancer, thoracic malignancies excluding mesothelioma
calcified non-pneumoconiotic nodules (e.g. granuloma) or nodes
calcification in small pneumoconiotic opacities
abnormality of cardiac size or shape
cor pulmonale
cavity
marked distortion of an intrathoracic structure
pleural effusion
emphysema

es
fr
hi
ho
id
ih

kl
me
pa
pb
pi
px

eggshell calcification of hilar or mediastinal lymph nodes
fractured rib(s) (acute or healed)
enlargement of non-calcified hilar or mediastinal lymph nodes
honeycomb lung
ill-defined diaphragm border - should be recorded only if more than
one-third of one hemidiaphragm is affected
ill-defined heart border - should be recorded only if the length of the heart
border affected, whether on the right or on the left side, is more than
one-third of the length of the left heart border
septal (Kerley) lines
mesothelioma
plate atelectasis
parenchymal bands - significant parenchymal fibrotic stands in continuity
with the pleura
pleural thickening of an interlobar fissure
pneumothorax

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

Abnormalities of the Diaphragm
Eventration
Hiatal hernia
Airway Disorders
Bronchovascular markings, heavy or increased
Hyperinflation
Bony Abnormalities
Bony chest cage abnormality
Fracture, healed (non-rib)
Fracture, not healed (non-rib)
Scoliosis
Vertebral column abnormality

Lung Parenchymal Abnormalities
Azygos lobe
Density, lung
Infiltrate
Nodule, nodular lesion
Miscellaneous Abnormalities
Foreign body
Post-surgical changes/sternal wire
Cyst
Vascular Disorders
Aorta, anomaly of
Vascular abnormality

4D. OTHER COMMENTS

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Public reporting burden of this collection of information is estimated to average 3 minutes per response, including 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 sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection
information, including suggestings for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS E-11, Atlanta,
GA 30333, ATTN: PRA (09020-0020). Do not send the completed form to this address.