Form CM-933b Radiologic Quality Rereading

U.S. Department of Labor

Radiologic Quality Rereading

Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation
OMB No. 1240-0023
Expires: XX/XX/XXXX

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.

Please record your quality finding of a single image 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 images of acceptable quality (1, 2 and 3). Images of inferior quality (U/R) must be retaken without cost to the
Department.
1A. Miner's Name (Print)
1C. Miner's Social Security Number
1D. Image Quality (If not Grade
1B. Date of X-ray
1. Give Reason):
Mo.

1

YR.

DAY

2A. ANY OTHER ABNORMALITIES ?

Complete
2B and 2C

YES

2

3

U/R

Proceed to
Section 3

NO

2B. OTHER SYMBOLS (OBLIGATORY)

aa
aa at

ax

bu

REPORT ITEMS WHICH
MAY BE OF PRESENT
CLINICAL SIGNIFICANCE
IN THIS SECTION.

ca

cg

ø

co

cp

cv

di

ef

em es

fr

hi

ho

id

ih

kl

me pa

pb

pi

px

ra

rp

»

Date Personal Physician notified?

(Specify od.)

Mo.

OD

Yr.

Day

2C. OTHER COMMENTS
2D. SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 2C?

Yes

Proceed to Section 3

No

3A. FACILITY PROVIDING ROENTGENOGRAPHIC EXAMINATION:
DOL Medical Provider Number (If applicable):

Was image taken by a registered radiographer/radiographic technologist?

Yes

No

State

Registration No.

Name

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

Yes

No

Board-eligible radiologist?

Yes

No

B-reader?

Yes

No

Date current B-reader certification expires:
3C. I certify that this image 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.

CM-933b (Rev. 2014)

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

ILO 2000 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
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
od

2C

-

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

CM-933b Page 2 (Rev. 2014)

Privacy Act Statement
The following statement is made in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a). This report is authorized by
law (30 USC 922 section 20 CFR 725.513). The information you furnish on this form may be routinely disclosed without your consent to
another person or Government agency for purposes such as (1) to comply with Federal laws requiring the release of information from
our records; or (2) to conduct research and audit activities needed to assure the continuing integrity and improvement of the U.S.
Department of Labor representative payee program. Other routine disclosures of this information are listed in the Federal Register,
which will be made available upon request.

Accommodation Statement
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive
help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims process. For
example, we will provide you with copies of documents in alternate formats, communication services such as sign language
interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or your
claims examiner to ask about this assistance.

CM-933b Page 3 (Rev. 2014)