National Coal Workers' Autopsy Study (42 cfr 37.204)

ATTACHMENT E

NCWAS Checklist

NATIONAL COAL WORKERS’ AUTOPSY STUDY (NCWAS)

Checklist

The following items must be complete to insure payment for services and for the autopsy to be included in the NCWAS database.

_______ Death must have occurred on or after May 14, 1971.

_______ Case must be received within 180 days of autopsy.

_______ Deceased must have worked in an underground mine.

_______ Must include the following articles:

_______ 3 blocks of lung tissue

_______ 3 stained slides of lung tissue

_______ completed and signed Consent, Release, and History

Form (CDC/NIOSH 2.6)

_______ Social Security Number (optional)

_______ Signed invoice with statement “No other form of compensation

has been received.”

_______ Autopsy protocol must include:

_______ heart and lung description and weights

_______ heart valve measurements

_______ heart ventricular measurements

_______ pathological diagnosis

_______ cause of death (optional on partial autopsies)

_______ clinical summary

_______ microscopic examination

_______ age, height, and weight

_______ Chest x-ray (PA) and interpretation made within 5 years

prior to death (optional)