Form 2.8 Chest Radiograph Classification

CHEST RADIOGRAPH CLASSIFICATION

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FEDERAL MINE SAFETY AND HEALTH ACT OF 1977
DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL & PREVENTION

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-

EXAMINEE'S Social Security Number

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OMB No.: 0920-0020
CDC/NIOSH (M) 2.8
REV. 01/2015

Coal Workers' Health Surveillance Program
National Institute for Occupational Safety and Health
1095 Willowdale Road, MS LB208
Morgantown, WV 26505
FAX: 304-285-6058

DATE OF RADIOGRAPH(mP-dG-\\\\)

FACILITY Number - Unit Number

-

TYPE OF READING
B

A

Full SSN is optional, last 4 digits are required.

F

Note: Please record your interpretation of a single radiograph by placing an "x" in the appropriate boxes on this form. Classify all appearances described in the ILO
International Classification of Radiographs of Pneumoconiosis or Illustrated by the ILO Standard Radiographs. Use symbols and record comments as appropriate.
IMAGE QUALITY

1.
1

2

3

U/R

(If not Grade 1, mark all
boxes that apply)

Overexposed (dark)

Improper position

Underinflation

Underexposed (light)

Poor contrast

Mottle

Artifacts

Poor processing

Other (please specify)

2A.

ANY CLASSIFIABLE PARENCHYMAL ABNORMALITIES?

2B.

SMALL OPACITIES

p

s

p

q

t

q

r
3A.
3B.

u

r

c. PROFUSION

b. ZONES

a. SHAPE/SIZE
PRIMARY
SECONDARY

R

2C.

s

UPPER

1/0 1/1 1/2

t

MIDDLE

2/1 2/2 2/3

u

LOWER

3/2 3/3 3/+

PLEURAL PLAQUES
Site

LARGE OPACITIES

In profile

R

Face on

O

R

Diaphragm

O

R

L

O

R

L

O

R

Other site(s)

O

R

L

O

R

L

1

2

R

L

3C.

COSTOPHRENIC ANGLE OBLITERATION

3D.

DIFFUSE PLEURAL THICKENING (mark site, calcification,

3

In profile

O

R

L

O

R

L

O

R

Face on

O

R

L

O

R

L

1

2

5.

PHYSICIAN'S Social Security Number*

-

1

2

Proceed to
Section 3A

C

YES

Proceed to
Section 4A

NO

Width (in profile only)
(3mm minimum width required)
3 to 5 mm = a
5 to 10 mm = b
> 10 mm = c

3

O

R

a

b

c

O

L

a

b

c

3

O

L

1

2

Width (in profile only)
(3mm minimum width required)
3 to 5 mm = a
5 to 10 mm = b
> 10 mm = c

3

O

R

a

b

NO

Complete Sections 4B, 4C, 4D, 4E

READER'S INITIALS

c

O

L

a

b

-

-

Full SSN is optional, last 4 digits are required.

PRINTED NAME (LAST, FIRST MIDDLE)

CITY

STREET ADDRESS

STATE

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Print

c

Complete physician info
and sign form.

DATE OF READING (mm-dd-yyyy)

-

SIGNATURE

Proceed to
Section 4A

NO

Extent (chest wall; combined for
in profile and face on)
Up to 1/4 of lateral chest wall = 1
1/4 to 1/2 of lateral chest wall = 2
> 1/2 of lateral chest wall = 3

Calcification

ANY OTHER ABNORMALITIES?

L

B

Proceed to
Section 3D

extent, and width)

4A.

O

A

Complete Sections
3B, 3C

YES

O

Site

O

SIZE

(mark site, calcification, extent, and width)
Extent (chest wall; combined for
Calcification
in profile and face on)
L
O R L
Up to 1/4 of lateral chest wall = 1
1/4 to 1/2 of lateral chest wall = 2
L
O R L
> 1/2 of lateral chest wall = 3

Chest wall

Proceed to
Section 3A

NO

0/- 0/0 0/1

L

ANY CLASSIFIABLE PLEURAL ABNORMALITIES?

Chest wall

Complete Sections
2B and 2C

YES

ZIP CODE

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4B.

OTHER SYMBOLS (OBLIGATORY)
aa

aa
at
ax

bu
ca
cg
cn
co
cp
cv
di
ef
em
es
fr

at

ax

bu

ca

cg

cn

co

cp

cv

di

ef

em

es

atherosclerotic aorta
significant apical pleural thickening
coalescence of small opacities - with margins of the small opacities
remaining visible, whereas a large opacity demonstrates a
homogeneous opaque appearance - may be recorded either in the
presence or in the absence of large 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 an intrathoracic structure
pleural effusion
emphysema
eggshell calcification of hilar or mediastinal lymph nodes
fractured rib(s) (acute or healed)

fr

hi

hi
ho
id
ih

kl
me
pa
pb
pi
px
ra
rp
tb

ho

id

ih

kl

me

pa

pb

pi

px

ra

rp

tb

enlargement of non-calcified hilar or mediastinal lymph nodes
honeycomb lung
ill-defined diaphragm border - should be recorded only if more than
one-third of one hemidiaphragm is affected
ill-defined heart border - should be recorded only if the length of the heart
border affected, whether on the right or on the left side, is more than
one-third of the length of the left heart border
septal (Kerley) lines
mesothelioma
plate atelectasis
parenchymal bands - significant parenchymal fibrotic stands in continuity
with the pleura
pleural thickening of an interlobar fissure
pneumothorax
rounded atelectasis
rheumatoid pneumoconiosis
tuberculosis

4C. MARK ALL BOXES THAT APPLY: (Use of this list is intended to reduce handwritten comments and is optional)

Abnormalities of the Diaphragm
Eventration

Hiatal hernia

Airway Disorders
Bronchovascular markings, heavy or increased
Hyperinflation
Bony Abnormalities

Lung Parenchymal Abnormalities
Azygos lobe

Density, lung

Infiltrate

Nodule, nodular
lesion

Miscellaneous Abnormalities
Foreign body
Post-surgical changes/sternal wire
Cyst
Vascular Disorders
Aorta, anomaly of

Vascular abnormality

Date Physician or Worker notified? (mm-dd-yyyy)

Bony chest cage abnormality

Fracture, healed (non-rib)

Fracture, not healed (non-rib)

Scoliosis

Vertebral
column abnormality

4E. Should worker see personal physician because of findings?

YES

NO

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-

4D. OTHER COMMENTS

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