Att 5_PHYSICIAN APPLICATION FOR CERTIFICATION

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PHYSICIAN APPLICATION FOR CERTIFICATION
Department of Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
NIOSH
Coal Workers’ Health Surveillance Program (CWHSP)
1095 Willowdale Road, M/S LB208
Morgantown, WV 26505
FAX: 304-285-6058
NIOSH READER ID

STATUS

FOR NIOSH USE ONLY

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

License #:

State:

License #:

NAME (LAST-FIRST-MIDDLE)

INITIALS

HOSPITAL OR DEPARTMENT

STREET ADDRESS

CITY

STATE

TELEPHONE NUMBER

OMB No.: 0920-0020

ZIP CODE

DATE OF BIRTH

COUNTRY

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:

Board Certified?

Secondary:

Primary
Secondary:

Yes
Yes

No
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)

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. CWHSP) Yes
Do you hold an active academic teaching appointment at a U.S. medical school? Yes

No

No

If yes, where?
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. 02/2019

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’ Health 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

EXAM SITE
D

EXAM FORMAT
A

D

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-24, Atlanta, GA 30333, ATTN: PRA (0920-0020).
Do not send the completed form to this address.
CDC 2.12 (E), Rev. 02/2019