0920-0020 Chest Radiograph Classification Form M 2.8 25MAR2019

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

EXAMINEE'S Social Security Number

OMB No.: 0920-0020
CDC/NIOSH (M) 2.8 REV. 02/2019

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

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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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CHEST RADIOGRAPH CLASSIFICATION

Full SSN is optional, last 4 digits are required.
EXAMINEE'S Name (Last, First MI)

FACILITY Number - Unit Number

TYPE OF READING
A

B

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

Excessive Edge
Enhancement

2A.

ANY CLASSIFIABLE PARENCHYMAL ABNORMALITIES?

2B.

SMALL OPACITIES

p

s

p

q

t

q

r
3A.
3B.

u

r

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.

NIOSH READER ID

1

2

3

YES

Proceed to
Section 3A

C

Proceed to
Section 4A

NO

O

R

a

b

c

O

L

a

b

c

Proceed to
Section 4A

NO

3

B

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

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

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

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)
Calcification
Extent (chest wall; combined for
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
c. PROFUSION

b. ZONES

a. SHAPE/SIZE
PRIMARY
SECONDARY

Other (specify)

O

L

1

2

3

O

R

a

b

NO

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

READER'S INITIALS

c

O

L

a

b

Complete physician info
and sign form.

DATE OF READING (mm-dd-yyyy)

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PRINTED NAME (LAST, FIRST MIDDLE)

SIGNATURE

CITY

STREET ADDRESS

STATE

CDC/NIOSH 2.8 (E), Revised 02/2019, CDC Adobe Acrobat 11.0, S508 Electronic Version

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c

ZIP CODE

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EXAMINEE'S Name (Last, First MI)

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
Lung Parenchymal Abnormalities

Eventration

Azygos lobe

Hiatal hernia

Density, lung

Airway Disorders
Infiltrate

Bronchovascular markings, heavy or increased
Nodule, nodular lesion

Hyperinflation
Miscellaneous Abnormalities

Bony Abnormalities
Foreign body

Post-surgical
changes/sternal wire
Bony chest cage abnormality

Cyst
Fracture, healed (non-rib)

Vascular
Disorders
Fracture, not healed (non-rib)

Aorta, anomaly of

Scoliosis

Vascular abnormality

Vertebral column abnorma

Date Physician or Worker notified? (mm-dd-yyyy)
4D. Should worker see personal physician because of findings?

YES

NO

4E. OTHER COMMENTS

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CDC/NIOSH 2.8 (E), Revised 02/2019, CDC Adobe Acrobat 11.0, S508 Electronic Version