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Roetgenographic Interpretation CM-933 - Official Federal Forms
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Roentgenographic Interpretation 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 required to obtain a benefit. The results of this interpretation will aid in OMB No. 1240-0023 determining the miner's eligibility for black lung benefits. Disclosure of a Social Security number is voluntary. The failure to disclose such Expires: 10/31/2014 number will not result in the denial of any right, benefit, or privilege to which the claimant may be entitled. This method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974, and OMB Circular No. 108. Please record your interpretation of a single film 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 social security number. The Department of Labor will pay only for films of acceptable quality (1, 2 and 3). Films of inferior quality (U/R) must be retaken without cost to the Department. 1. Miner's Name (Print) 1A. Date of X-Ray 1B. Miner's Social Security Number 1C. Film Quality (if not Grade 1. Give Reason): 1 MO 1D. Is Film Completely Negative? YES Proceed to Section 5 a. SHAPE/SIZE PRIMARY p q r s t u SECONDARY p q r s t u R 3A. ANY PLEURAL ABNORMALITIES CONSISTENT WITH PNEUMOCONIOSIS? YES Complete Sections 3B, 3C NO Proceed to Section 4A L b. ZONES 0/1/0 2/1 3/2 NO Complete Section 2A c. PROFUSION 0/0 1/1 2/2 3/3 0/1 1/2 2/3 3/+ SIZE O A B C Proceed to Section 3 DAY YR 2A. Any Parenchymal Abnormalities Consistent with Pneumoconiosis? YES Complete 2B and 2C NO Proceed to Section 3 2 3 U/R 2B. Small Opacities Consistent With Pneumoconiosis 2C. Large Opacities Consistent With Pneumoconiosis 3B. PLEURAL PLAQUES Chest Wall In Profile Face On Diaphragm Other site(s) (mark site, calcification, extent and width) O O O O Site R R R R L L L L Calcification O R L O O O R R R L L L 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 O 1 R 2 3 O 1 L 2 3 Width (in profile only) (3mm minimum width required) 3 to 5 mm = a 5 to 10 mm = b > 10 mm = c O a R b c O a L b c 3C. COSTOPHRENIC ANGLE OBLITERATION R L Proceed to Section 3D Extent (chest wall, combined for in profile and face on) NO Proceed to Section 4A 3D. DIFFUSE PLEURAL THICKENING (mark site, calcification, extent, and width) Chest wall In Profile Face On O O Site R R L L Calcification O O R R L L 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 O 1 R 2 3 O 1 L 2 3 Width (in profile only) (3m minimum width required) 3 to 5 mm = a 5 to 10 mm = b > 10 mm = c O a R b c O a L b c 4A. ANY OTHER ABNORMALITIES? YES 4B. OTHER SYMBOLS (OBLIGATORY) aa at ax bu ca cg cn co cp cv di ef em Complete 4B and 4C NO Proceed to Section 5 es fr hi ho id ih kl me pa M pb pi o. px D ra ay rp Y tb r. REPORT ITEMS WHICH MAY BE OF PRESENT CLINICAL SIGNIFICANCE IN THIS SECTION OTHER COMMENTS 4C OD (Specify od.) Date Personal Physician notified? SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 4C? 5A. FACILITY PROVIDING ROENTGENOGRAPHIC EXAMINATION: DOL Medical Provider Number (if applicable): Was film taken by a registered radiographer/radiographic technologist? Name Yes No YES NO Proceed to Section 5 State Registration No. 5B. Physician Interpreting Film (Print Name): ___________________________________________________________________________________ Are you: Board-Certified Radiologist? Yes No. Board-eligible radiologist? Yes No. B-reader? Yes No 5C. I certify that this film has been interpreted in accordance with the instructions provided on Form CM-954a and/or 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 under Title 30 USC 941 shall be guilty of a misdemeanor and subject to a fine of up to $1,000, or to imprisonment for up to one year, or both. PHYSICIAN'S SIGNATURE ____________________________________________________________ DATE OF READING_________________________________________________ (Mo., Day, Yr.) Public Burden Statement We estimate that it will take an average of 5 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 survey, 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 NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. American LegalNet, Inc. www.FormsWorkFlow.com CM-933 (Rev. 01-11) FEATURES Technical Quality Parenchymal Abnormalities Small Opacities For Purpose of Coding for the Department of Labor, the following codes will be used ILO 2000 INTERNATIONAL CLASSIFICATION OF RADIOGRAPHS OF THE PNEUMOCONIOSES CODES DEFINITIONS 1 Good Acceptable, with no technical defect likely to impair classification of 2 the radiograph for pneumoconiosis. 3 Poor, with some technical defect but still acceptable for classification purposes. Unacceptable. 4 The category of profusion is based on the assessment of concentration 0/- 0/0 0/1 of opacities by comparison with the standard radiographs. Profusion 1/0 1/1 1/2 Category 0 small opacities absent or less profuse than the lower limit 2/1 2/2 2/3 of Category 1. 3/2 3/3 3/+ Categories 1, 2 and 3 represent increasing profusion of small opacities as defined by the corresponding standard radiographs. Extent RU RM RL The zones in which the opacities are seen are recorded. The right (R) and left (L) thorax are both divided into three zones upper (U), middle (M) LU LM LL and lower (L). Shape and Size rounded The category of profusion is determined by considering
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