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FEDERAL MINE SAFETY AND HEALTH ACT OF 1977
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL & PREVENTION
-
-
EXAMINEE'S Social Security Number
-
-
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
Save Form
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
-
-
4D. OTHER COMMENTS
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