Form CM-933b Radiologic Quality Rereading

Radiologic Quality Rereading

U. S. Department of Labor
Office of Workers’ Compensation Programs
Division of Coal Mine Workers’ Compensation

NOTE: This report is authorized by law (30 USC, 901 et seq. and 20 CFR 718.102). The results of this interpretation will aid in
determining the miner’s eligibility for black lung benefits. This method of collecting information complies with the Freedom of
Information Act, the Privacy Act of 1974, and OMB Cir. No. 108.

OMB No. 1240-0023
Expires: XX/XX/XXXX

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 DOL’s Case ID 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)

1B. Date of X-ray

1C. DOL’s Case ID Number

1D. Image Quality (If not Grade
1 give reason):
1

MO.

DAY

2A. ANY OTHER ABNORMALITIES?

2

3

U/R

YR.
Complete
2B and 2C

YES

Proceed to
Section 3

NO

2B. OTHER SYMBOLS (OBLIGATORY)
aa

at

ax

bu

ca

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

cg

cn

OD

co

cp

cv

di

ef

em

es

fr

(Specify od.)

hi

ho

id

ih

kl

me

pa

pb

Date Personal Physician notified?

pi

px

Mo.

ra

rp

Day

tb

Yr.

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

Yes

No

Proceed to Section 3

3A. FACILITY PROVIDING ROENTGENOGRAPHIC EXAMINATION: ___________________________________________________________________
DOL Medical Provider Number (if applicable): ___________________________________________________________________________________
Was image taken by a registered radiographer/radiographic technologist?

□

Yes

Name ___________________________________________________________

□

No

___________________________________
State
Registration No. _______________________________________

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

□

Yes

□

No

Board-eligible Radiologist?

□

Date current B-reader certification expires: _______________________________

Yes

□

No

B-reader?

□

Yes

□

No

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
shall be guilty under 30 USC 941 of a misdemeanor and, on conviction, 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 information
collection, 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.
PRIVACY ACT NOTICE
The following information is provided in accordance with the Privacy Act of 1974, 5 USC 552a. (1) Submission of this information is required under the Black Lung Benefits Act.
(2) The information will be used to determine eligibility for and the amount of benefits payable under the Act. (3) The information may be used by other agencies or persons in
handling matters relating, directly or indirectly, to the subject matter of the claim, including potentially liable coal mine operators and their insurance carriers; medical professionals
in obtaining medical services or evaluations; contractors providing automated data processing services to the Department of Labor; representatives of the parties to the claim; and
federal, state or local agencies in obtaining information about eligibility for benefits. (4) Furnishing all requested information will facilitate the claims adjudication process; not
providing all or any part of the requested information may delay the process, or result in an unfavorable decision or a reduced level of benefits. (5) This information is included in
a System of Records, DOL/OWCP-2, published at 81 Federal Register 25765, 25858 (April 29, 2016), or as updated and republished.
NOTICE
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
the claims examiner to ask about this assistance.

NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number

CM-933b (Rev. 2017)

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

ILO 2011 INTERNATIONAL CLASSIFICATION OF RADIOGRAPHS OF THE PNEUMOCONIOSES

1D

Technical Quality
CODES

DEFINITIONS

1
2

-

3
U/R

-

2B

Good
Acceptable, with no technical defect likely to impair classification of the radiograph for
pneumoconiosis
Acceptable, with some technical defect but still acceptable for classification purposes.
Unacceptable for classification purposes.

Other Symbols

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.

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

DEFINITIONS
-

atherosclerotic aorta
significant apical pleural thickening
coalescence of small opacities
bulla(e)
cancer: thoracic malignancies excluding mesothelioma
calcified non-pneumoconiotic nodules (e.g. granuloma) or nodes
calcification in small pneumoconiotic opacities
abnormality of cardiac size or shape
cor pulmonale
cavity
marked distortion of the intrathoracic structure
pleural effusion
emphysema
eggshell calcification of hilar or mediastinal lymph nodes
fractured rib(s) (acute or healed)
enlargement of non-calcified hilar or mediastinal lymph nodes
honeycomb lung
ill-defined diaphragm border
ill-defined heart border
septal (Kerley) lines
mesothelioma
plate atelectasis
parenchymal bands
pleural thickening in the interlobar fissure
pneumothorax
rounded atelectasis
rheumatoid pneumoconiosis
tuberculosis
other disease or significant abnormality

Comments

If comments are present, please check the “Yes” or “No” box to indicate if the miner should see personal physician.

CM-933b (Rev. 2017)
2