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.

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

1

2

3

U/R

1C. DOL’s Case ID Number

2B. OTHER SYMBOLS (OBLIGATORY)

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

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

2C. OTHER COMMENTS

(Specify od.) Date Personal Physician notified?

3A. FACILITY PROVIDING ROENTGENOGRAPHIC EXAMINATION:

DOL Medical Provider Number (if applicable): Was image taken by a registered radiographer/radiographic technologist? □ Yes □ No

State

Name Registration No.

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

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.)

TWO FILING OPTIONS:

1. To file electronically, submit completed form to the COAL Mine Portal:

https://eclaimant.dol-esa.gov/bl

2. To file by mail, send completed form to:

US Department of Labor

OWCP/DCMWC

PO Box 33610

San Antonio, TX 78265

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 Systems of Records DOL/OWCP-2 and DOL/OWCP-9, published at 81 Federal Register 25765, 25858, 25866 (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. April 2020)

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	Good Acceptable, with no technical defect likely to impair classification of the radiographpneumoconiosis Acceptable, with some technical defect but still acceptable for classification purposes. Unacceptable for classification purposes.	for
	2
	3
	U/R
2B	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	DEFINITIONS
	aa	- atherosclerotic aorta
	at	- significant apical pleural thickening
	ax	- coalescence of small opacities
	bu	- bulla(e)
	ca	- cancer: thoracic malignancies excluding mesothelioma
	cg	- calcified non-pneumoconiotic nodules (e.g. granuloma) or nodes
	cn	- calcification in small pneumoconiotic opacities
	co	- abnormality of cardiac size or shape
	cp	- cor pulmonale
	cv	- cavity
	di	- marked distortion of the intrathoracic structure
	ef	- pleural effusion
	em	- emphysema
	es	- eggshell calcification of hilar or mediastinal lymph nodes
	fr	- fractured rib(s) (acute or healed)
	hi	- enlargement of non-calcified hilar or mediastinal lymph nodes
	ho	- honeycomb lung
	id	- ill-defined diaphragm border
	ih	- ill-defined heart border
	kl	- septal (Kerley) lines
	me	- mesothelioma
	pa	- plate atelectasis
	pb	- parenchymal bands
	pi	- pleural thickening in the interlobar fissure
	px	- pneumothorax
	ra	- rounded atelectasis
	rp	- rheumatoid pneumoconiosis
	tb	- tuberculosis
	od	- other disease or significant abnormality
2C		Comments
If comments are present, please check the “Yes” or “No” box to indicate if the miner should see personal physician.

CM-933b (Rev. April 2020)

2