Invoice-Pathologist (CWHSP)

National Coal Workers' X-ray Surveillance Program (CWXSP) - Federal Mine Safety and Health Act 1977 (42CFR37)

Att 12_Autopsy Study (NCWAS) Checklist

Invoice-Pathologist (CWHSP)

OMB: 0920-0020

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Attachment 12

NCWAS Autopsy Checklist

NATIONAL COAL WORKERS’ AUTOPSY STUDY (NCWAS)

Checklist

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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)





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