Medical History and Examination for

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3A. ANY PLEURAL ABNORMALITIES 
       CONSISTENT WITH PNEUMOCONIOSIS?                                                                                                                      YES

Complete Sections
NO

Proceed to


3B, 3C


Section 4A

3B. PLEURAL PLAQUES   (mark site, calcification, extent and width)

Extent (chest wall; combined for



Width (in profile only)

















in profile and face on)



(3mm minimum width required)




Chest Wall
Site


Calcification


Up to 1/4 of lateral chest wall = 1



  3 to 5 mm = a




In Profile
O
R
L


O
R
L


1/4 to 1/2 of lateral chest wall = 2



5 to 10 mm = b




Face On
O
R
L


O
R
L


      > 1/2 of lateral chest wall = 3



    > 10 mm = c




Diaphragm
O
R
L


O
R
L


O
R



O
L




O
R



O
L





Other site(s)
O
R
L


O
R
L


1
2
3


1
2
3



a
b
c


a
b
c






































3C. COSTOPHRENIC ANGLE OBLITERATION
R
L
Proceed to
Section 3D
NO

Proceed to
Section 4A

3D.  DIFFUSE PLEURAL THICKENING  (mark site, calcification, extent, and width)


Extent (chest wall, combined for



Width (in profile only)



















in profile and face on)



(3m minimum width required)



















Up to 1/4 of lateral chest wall = 1



  3 to 5 mm = a



















1/4 to 1/2 of lateral chest wall = 2



5 to 10 mm = b




Chest wall
Site


Calcification



       > 1/2 of lateral chest wall = 3



    > 10 mm = c




In Profile
O
R
L


O
R
L



O
R


O
L




O
R


O
L





Face On
O
R
L


O
R
L



1
2
3

1
2
3



a
b
c

a
b
c




































4A.  ANY OTHER ABNORMALITIES?
YES

Complete
NO

Proceed to


4B and 4C


Section 5


4B. OTHER SYMBOLS (OBLIGATORY)

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

REPORT ITEMS WHICH

MAY BE OF PRESENT

OD

(Specify od.)


Date Personal Physician notified?

M
o.
D
ay
Y
r.
CLINICAL SIGNIFICANCE










IN THIS SECTION

4C
OTHER COMMENTS 





SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 4C?
YES
NO
Proceed to Section 5



5A.
FACILITY PROVIDING ROENTGENOGRAPHIC EXAMINATION:


DOL Medical Provider Number (if applicable):


Was film taken by a registered radiographer/radiographic technologist?
□  Yes      □   No





State

Name

Registration No.


5B.  Physician Interpreting Film (Print Name):  ___________________________________________________________________________________
        Are you:  Board-Certified Radiologist?  □ Yes   □ No.            Board-eligible radiologist?   □ Yes   □ No.                   B-reader?  □  Yes   □  No
5C.  I certify that this film has been interpreted in accordance with the instructions provided on Form CM-954a and/or 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 READING_________________________________________________
                                                                                                                                                                                                                                                        (Mo., Day, Yr.)
Public Burden Statement
We estimate that it will take an average of 5 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.
CM-933 (Rev. 01-11)

For Purpose of Coding for the Department of Labor, the following codes will be used
ILO 2000 INTERNATIONAL CLASSIFICATION OF RADIOGRAPHS OF THE PNEUMOCONIOSES
FEATURES
CODES
DEFINITIONS
Technical Quality
 
 
1

Good
Acceptable, with no technical defect likely to impair classification of
the radiograph for pneumoconiosis.
Poor, with some technical defect but still acceptable for classification
purposes.
Unacceptable.
The category of profusion is based on the assessment of concentration
of opacities by comparison with the standard radiographs.
Category 0 – small opacities absent or less profuse than the lower limit
of Category 1.
Categories 1, 2 and 3 – represent increasing profusion of small opacities as defined by the corresponding standard radiographs.
The zones in which the opacities are seen are recorded.  The right (R) and
left (L) thorax are both divided into three zones – upper (U), middle (M)
and lower (L).

The category of profusion is determined by considering the profusion as a whole over the affected zones of the lung and by comparing this with the standard radiographs.
The letters p, q, and r denote the presence of small rounded opacities.
Three sizes are defined by the appearances on standard radiographs.
p = diameter up to about 1.5 mm.
q = diameter exceeding about 1.5 mm and up to about 3 mm.
r = diameter exceeding about 3 mm and up to about 10 mm.
The letters s, t and u denote the presence of small irregular opacities.
Three sizes are defined by the appearance on standard radiographs.
s = width up to about 1.5 mm.
t = width exceeding about 1.5 mm and up to about 3 mm.
u = width exceeding 3 mm and up to about 10 mm.
For mixed shapes (or sizes) of small opacities the predominant shape
And size is recorded first.  The presence of a significant number or another shape and size is recorded after the oblique stroke.



2



Parenchymal


3


Abnormalities
Small Opacities


4





Profusion
0/-   0/0   0/1
1/0  1/1   1/2
2/1  2/2   2/3
3/2  3/3   3/+













Extent




RU  RM  RL

LU  LM  LL




Shape and Size





rounded
p/p  q/q  r/r









irregular


mixed 





s/s t/t u/u

p/s p/t p/u  p/q p/r
q/w q/t q/u q/p q/r
r/s  r/t  r/u  r/p  r/q
s/p s/q s/r  s/t  s/u
t/p  t/q  t/r   t/s  t/u
u/p u/q u/r  u/s u/t


Large Opacities








Pleural Abnormalities


Pleural Thickening
Chest Wall












Type

Site
A B C 




The categories are defined in terms of dimensions of the opacities.
Category A – an opacity having a greatest diameter exceeding about 10
mm and up to and including 50 mm, or several opacities each greater
than about 10 mm, the sum of whose greatest diameters does not 
exceed 50 mm.
Category B – one or more opacities larger or more numerous
than those in category A whose combined area does not exceed the 
equivalent of the right upper zone.
Category C – one or more opacities whose combined area does not
exceed the equivalent of the right upper zone.
Two types of pleural thickening of the chest wall are recognized:
circumscribed (plaques) and diffuse.  Both types may occur together.



R    L

Pleural thickening of the chest wall is recorded separately for  the
right (R) and left (L) thorax.


Width
A B C

For pleural thickening seen along the lateral chest wall the 
measurement of maximum width is made from the inner line of the
chest wall to the inner margin of the shadow seen most sharply at the
parenchymal-pleural boundary.  The maximum width usually occurs at 
the inner margin of the rib shadow at its outermost point.
a = maximum width up to about 5 mm.
b = maximum width over about 5 mm and up to about 10 mm.
c = maximum width over about 10 mm.


Face On
Y    N

The presence of pleural thickening seen face-on is recorded even if it
can be seen also in profile.  If pleural thickening is seen face-on only,
width can not usually be measured.











Extent









1  2  3 

Extent of pleural thickening is defined in terms of the maximum
length of pleural involvement, or as the sum of maximum lengths, 
whether seen in profile or face-on.
1 = total length equivalent up to one quarter of the projection of the
      lateral chest wall.
2 = total length exceed one quarter but not one half of the projection
      of the lateral chest wall.
3 = total length exceeding one half of the projection of the lateral chest 
      lateral chest wall
Diaphragm

Costophrenic Angle




Pleural Calcification


















Symbols

Presence 

Site
Presence


Site

Site
chest wall
diaphragm
other

extent

Y     N

R     L
Y     N


R     L


R     L
R     L
R     L

1      2      3 

A plaque involving the diaphragmatic pleura is recorded as present (Y)
or absent (N) separately for the right (R) or left (L) thorax.
The presence (Y) or absence (N) costophrenic angle obliteration is
recorded separately from thickening over other areas for the right (R)
and left (L) thorax.  The lower limit for the obliteration is defined by a
standard radiograph.
If the thickening extends up the chest wall then both costophrenic
angle obliteration and pleural thickening should be recorded.
The site and extent of pleural calcification are recorded separately for
the two lungs, and the extent defined in terms of dimensions.
“Other” includes calcification of the mediastinal and pericardial pleura.
1 = an area of calcified pleura with greatest diameter up to about 20 mm
      or a number of such areas the sum of whose greatest diameters
      does not exceed about 20 mm.
2 = an area of calcified pleura with greatest diameter exceeding about
      20 mm and up to about 100 mm, or a number of such areas the
      sum of whose greatest diameters exceed about 20 mm but dies not
      exceed about 100 mm.
3 = an area of calcified pleura with greatest diameter exceeding about 
      100 mm or a number of such area whose sum of greatest diameters
      exceeds about 100 mm.
It is to be taken that the definition of such of the Symbols is preceded
by an appropriate word or phrase such as “suspect” , “pneumoconiotic
changes suggestive of“, or “opacities suggestive of “, etc.

aa
- atherosclerotic

hi
- enlargement of hilar or mediastinal lymph nodes
at
- significant apical pleural thickening

ho
- honeycomb lung
ax
- coalescence of small pneumoconiotic opacities
   
id
- ill defined diaphragm
bu
- bulla(e)

ih
- ill defined heart outline
ca
- cancer of lung or pleura

kl
- septal (kerley) lines
cg
- calcified non-pneumoconiotic opacities

me
- mesothelioma
cn
- calcification in small pneumoconiotic opacities

pa
- plate atelectasis
co
- abnormality of cardiac size or shape

pb
- parenchymal bands
cp
- cor pulmonale

pi
- pleural thickening in the interlobar fissue
cv
- cavity

px
- pneumothorax
di
- marked distortion of the intrathoracic organs

ra
- rounded atelactasis
ef
- effusion

rp
- rheumatoid pneumoconiosis
em
- definite emphysema

tb
- tuberculosis
es
- eggshell calcification of hilar or mediastinal lymph nodes

od
- other significant abnormality
fr
- fractured rib(s) (acute or healed)



Comments

Presence
Y        N

Comments should be recorded pertaining to the classification of the radiograph particularly if some other cause is thought to be responsible for a shadow.
CM-933 PAGE 2(Rev. 01-11)