CM933b Roentgenographic 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: 12/31/2023

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

2

3

U/R

MO.

DAY

YR.

2A. ANY OTHER ABNORMALITIES?

YES

Complete 2B and 2C

NO

Proceed to Section 3

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

OD

(Specify od.)

Date Personal Physician notified?

Mo.

Day

Yr.

2C. OTHER COMMENTS

No Yes 2D. SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 2C? 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 □ 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: To file electronically, submit completed form to the COAL Mine Portal: https://eclaimant.dol.gov/portal/?program_name=BL To file by mail, send completed form to: US Department of Labor OWCP/DCMWC PO Box 8307 London, KY 40742-8307 CM-933b (Rev. April 2020)

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 In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) the Black Lung Benefits Act (BLBA) (30 U.S.C. 901 et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives and maintains personal information, relative to this application, on claimants and their immediate families; (2) information obtained by OWCP will be used to determine eligibility for benefits payable under the BLBA; (3) information may be given to other government agencies, coal mine operators potentially liable for payment of the claim or to the insurance carrier or other entity which secured the operator's compensation liability, contractors providing automated data processing services to the Department of Labor; and representatives of the parties to the claim; (4) information may be given to physicians or other medical service providers for use in providing treatment, making evaluations and for other purposes relating to the medical management of the claim; (5) information may be given to the Department of Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to render decisions with respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local agencies for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have been paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law; (7) disclosure of the claimant's or deceased miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary, and the SSN and/or TIN and other information maintained by the OWCP may be used for identification and for other purposes authorized by law; (8) failure to disclose all requested information, may delay the processing of this claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits; and (9) 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. 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 2 3 U/R	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.
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 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	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
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)