Form 2.12 Physician Application for Certification

Attachment 12 –

Physician Application for Certification – Form 2.12

Form Approved

OMB No.: 0920-0020

Exp. Date xx/xx/20xx

PHYSICIAN APPLICATION FOR CERTIFICATION Department of Health and Human Services Centers for Disease Control and Prevention National Institute for Occupational Safety and Health

STATUS

FOR NIOSH USE ONLY

RETURN TO

NIOSH Coal Workers’ Health Surveillance Program 1095 Willowdale Road, M/S LB208 Morgantown, WV 26505 FAX: 304-285-6058

ACTIVE STATE LICENSE(S) State: ______ License #: __________________ State: ______ License #: __________________ State: ______ License #: __________________

SOCIAL SECURITY NUMBER (Full SSN is optional; last 4 digits are required)

NAME (LAST-FIRST-MIDDLE)

INITIALS

DATE OF BIRTH

HOSPITAL OR DEPARTMENT

STREET ADDRESS

CITY

STATE

ZIP CODE

COUNTRY

TELEPHONE NUMBER

EMAIL ADDRESS

During the last year, average number of chest radiographs viewed and assessed per month: ______ During the last year, average number of chest radiographs classified according to ILO system per month: ______

SPECIALITY:

Primary: ________________________ Secondary: ______________________

Board Certified?

Primary

Yes

No

Secondary:

Yes

No

I am applying to be an A Reader, and

I am submitting six chest radiographs, along with my classifications performed according the Guidelines for the use of the ILO International Classification of Radiographs of Pneumoconioses; or

I have taken instruction in the current edition of the ILO International Classification of Radiographs of Pneumoconioses I attended the approved course at: ______________________ on _________________ City Date

I am applying to be a B Reader, and

I have most recently taken the B Reader Certification exam at: ____________________ on _____________ City Date

I have most recently taken the B Reader Recertification exam at: __________________ on ______________ City Date

I want my name and contact information included on the CDC Internet listing of physicians who have demonstrated competence in applying the ILO classification by successfully completing the NIOSH B Reader examination.

Are you employed by a Federal Government Agency?

Yes

No

If so, which one and where is your duty station? _______________________________________________________

Would you be interested in classifying chest radiographic images for NIOSH programs (e.g. the Coal Workers’

Health Surveillance Program)?

Yes

No

Do you anticipate that you will use this certification to document your credentials to classify chest radiographs for

other (non-NIOSH) programs or purposes?

Government Programs

Yes

No

Medical-Legal Activities

Yes

No

Individual Patient Care

Yes

No

Occupational Health Programs

Yes

No

Investigations / Research

Yes

No

Other (describe below)

Yes

No

Describe “other” activity: ____________________________________________________________________

CDC 2.12 (E), Rev. 01/2015

I agree that I will abide by the B Reader Code of Ethics when classifying chest radiographic images. If I participate in the Coal Workers’ X-Ray Surveillance Program, my performance will be conducted in the manner specified by HHS regulation 42 C.F.R. Part 37, and I understand that information related to classifications of individual radiographs made in connection with this program will be treated in a secure manner and will not be disclosed, unless otherwise compelled by law. I further understand that: 1) My B Reader certification requires an active license to practice medicine in the United States and I must notify the NIOSH B Reader Program within 60 days if my medical license is revoked, suspended, voluntarily relinquished or surrendered, or converted to inactive status*; 2) NIOSH does not regulate or monitor my classification of chest images performed for non-NIOSH purposes; 3) If NIOSH becomes aware of violations, or allegations of violations, of the B Reader Code of Ethics, it may, at its discretion, notify appropriate authorities, including the applicable State Board(s) of Medicine. *Send written notification to: NIOSH Coal Workers’ Health Surveillance Program, 1095 Willowdale Road, M/S LB208, Morgantown, WV 26505
DATE		PHYSICIAN SIGNATURE
FOR NIOSH USE ONLY
CERT DATE	DATE OF EXAM		TYPE OF EXAM B R	SCORE	STUDY METHOD A B C D	EXAM SITE
Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the 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 of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0020). Do not send the completed form to this address.

CDC 2.12 (E), Rev. 01/2015