Form 2.12 Physician Application for Certification

National Coal Workers' Health Surveillance Program (CWHSP)

Attachment 12

Physician Application for Certification (CDC/NIOSH 2.12)

OMB: 0920-0020

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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

Shape1

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


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