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Roentgenographic Interpretation
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Radiologic 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 20 CFR 718.102). The results of this interpretation will aid in determining the claimant’s eligibility for OMB No. 1240-0023
black lung benefits. This method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974, and OMB Circular No. 108. Expires 11/30/2026
Please record your interpretation 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.
1. Miner’s Name (Print) 1A. Date of X-Ray 1B. DOL’s Case ID Number 1C. Image Quality (if not Grade
1. Give Reason):
1 2 3 U/R
MO DAY YR
1D. Is Image Completely Negative? 2A. Any Parenchymal Abnormalities Consistent with Pneumoconiosis?
YES □ Proceed to Section 5 NO □ Complete Section 2A YES □ Complete 2B and 2C NO □ Proceed to Section 3
2B. Small Opacities Consistent With Pneumoconiosis 2C. Large Opacities Consistent With Pneumoconiosis
a. SHAPE/SIZE c. PROFUSION
PRIMARY SECONDARY b. ZONES 0/- 0/0 0/1
p s p s 1/0 1/1 1/2
Proceed to
q t q t 2/1 2/2 2/3 O A B C
SIZE Section 3
r u r u 3/2 3/3 3/+
R L
3A. ANY PLEURAL ABNORMALITIES
Complete Sections Proceed to
CONSISTENT WITH PNEUMOCONIOSIS? YES NO
3B, 3C Section 4A
3B. PLEURAL PLAQUES (mark site, calcification, extent and width) Extent (chest wall; combined for Width (in profile only)
in profile and face on) (3mm minimum width required)
Chest Wall Site Calcification Up to 1/4 of lateral chest wall = 1 3 to 5 mm = a
In Profile O R L O R L 1/4 to 1/2 of lateral chest wall = 2 5 to 10 mm = b
Face On O R L O R L > 1/2 of lateral chest wall = 3 > 10 mm = c
Diaphragm O R L O R L O R O L O R O L
Other site(s) O R L O R L 1 2 3 1 2 3 a b c a b c
Proceed to Proceed to
3C. COSTOPHRENIC ANGLE OBLITERATION R L NO
Section 3D Section 4A
3D. DIFFUSE PLEURAL THICKENING (mark site, calcification, extent, and width) Extent (chest wall, combined for Width (in profile only)
in profile and face on) (3mm minimum width required)
Up to 1/4 of lateral chest wall = 1 3 to 5 mm = a
1/4 to 1/2 of lateral chest wall = 2 5 to 10 mm = b
Chest wall Site Calcification > 1/2 of lateral chest wall = 3 > 10 mm = c
In Profile O R L O R L O R O L O R O L
Face On O R L O R L 1 2 3 1 2 3 a b c a b c
4A. ANY OTHER ABNORMALITIES?
Complete Proceed to
YES NO
4B and 4C Section 5
4B. 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 (Specify od.) Date Personal Physician notified?
OD M M D D Y Y
CLINICAL SIGNIFICANCE
IN THIS SECTION
4C OTHER COMMENTS
SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 4C? YES NO Proceed to Section 5
5A. FACILITY PROVIDING RADIOLOGIC EXAMINATION:
DOL Medical Provider Number (if applicable):
Was image taken by a registered radiographer/radiographic technologist? □ Yes □ No
State
Name Registration No.
5B. 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: ______________
5C. I certify that this image 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
statement or representation in support of an application for benefits shall be guilty of a misdemeanor under 30 USC 941 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 READING_________________________________________________
(Mo., Day, Yr.)
CM-933 (Rev. April 2020)
TWO FILING OPTIONS:
1. To file electronically, submit completed form to the COAL Mine Portal:
https://coalmine.dol.gov
2. To file by mail, send completed form to:
US Department of Labor
OWCP/DCMWC
PO Box 8307
London, KY 40742-8307
For Further Information call TOLL FREE: 1-800-347-2502
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
information collection, including suggestions for reducing this burden, send them to the Division of Coal Mine Workers’ Compensation, U. S. Department of Labor, 200
Constitution Avenue, N.W., Suite C3520-DCMWC, 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-933 (Rev. April of 2020)
2
For Purpose of Coding for the Department of Labor, the following codes will be used
ILO 2011 INTERNATIONAL CLASSIFICATION OF RADIOGRAPHS OF THE PNEUMOCONIOSES
FEATURES CODES DEFINITIONS
Technical Quality 1 Good
2 Acceptable, with no technical defect likely to impair classification of
the radiograph for pneumoconiosis.
Parenchymal 3 Acceptable, with some technical defect but still acceptable for classification
Abnormalities purposes.
Small Opacities U/R Unacceptable for classification purposes.
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.
Zones 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).
The category of profusion is determined by considering the profusion as a whole over the affected
zones of the lung and by comparing this with the standard radiographs.
Shape and Size The letters p, q, and r denote the presence of small rounded opacities.
rounded p/p q/q r/r Three sizes are defined by the appearances on standard radiographs.
p = diameter up to about 1.5 mm.
q = diameter exceeding about 1.5 mm and up to about 3 mm.
irregular s/s t/t u/u r = diameter exceeding about 3 mm and up to about 10 mm.
The letters s, t and u denote the presence of small irregular opacities.
Three sizes are defined by the appearance on standard radiographs.
p/s p/t p/u p/q p/r
mixed q/s q/t q/u q/p q/r s = width up to about 1.5 mm.
r/s r/t r/u r/p r/q t = width exceeding about 1.5 mm and up to about 3 mm.
s/p s/q s/r s/t s/u
t/p t/q t/r t/s t/u u = width exceeding 3 mm and up to about 10 mm.
u/p u/q u/r u/s u/t
For mixed shapes (or sizes) of small opacities the predominant shape
And size is recorded first. The presence of a significant number or another shape and size is
recorded after the oblique stroke.
Large Opacities ABC The categories are defined in terms of dimensions of the opacities.
Category A – an opacity having a greatest diameter exceeding about 10
mm and up to and including 50 mm, or several opacities each greater
than about 10 mm, the sum of whose greatest diameters does not
exceed 50 mm.
Category B – one or more opacities larger or more numerous
than those in category A whose combined area does not exceed the
equivalent of the right upper zone.
Pleural Abnormalities
Category C – one or more opacities whose combined area
Type exceed the equivalent of the right upper zone.
Pleural Thickening
Chest Wall Site Two types of pleural thickening of the chest wall are recognized:
circumscribed (plaques) and diffuse. Both types may occur together.
R L Pleural thickening of the chest wall is recorded separately for the
right (R) and left (L) thorax.
Width ABC For pleural thickening seen along the lateral chest wall the
measurement of maximum width is made from the inner line of the
chest wall to the inner margin of the shadow seen most sharply at the
parenchymal-pleural boundary. The maximum width usually occurs at
the inner margin of the rib shadow at its outermost point.
a = maximum width up to about 5 mm.
b = maximum width over about 5 mm and up to about 10 mm.
c = maximum width over about 10 mm.
Face On Y N The presence of pleural thickening seen face-on is recorded even if it
can be seen also in profile. If pleural thickening is seen face-on only,
width cannot usually be measured.
Extent 123 Extent of pleural thickening is defined in terms of the maximum
length of pleural involvement, or as the sum of maximum lengths,
whether seen in profile or face-on.
1 = total length equivalent up to one quarter of the projection of the
lateral chest wall.
2 = total length exceed one quarter but not one half of the projection
of the lateral chest wall.
3 = total length exceeding one half of the projection of the lateral chest
lateral chest wall
Diaphragm Presence YN A plaque involving the diaphragmatic pleura is recorded as present (Y)
Costophrenic Angle or absent (N) separately for the right (R) or left (L) thorax.
Site R L The presence (Y) or absence (N) costophrenic angle obliteration is
Presence Y N recorded separately from thickening over other areas for the right (R)
and left (L) thorax. The lower limit for the obliteration is defined by a
standard radiograph showing profusion subcategory 1/1 t/t.
Pleural Calcification Site R L If the thickening extends up the chest wall then both costophrenic
angle obliteration and pleural thickening should be recorded.
Site The site and extent of pleural calcification are recorded separately for
chest wall R L
the two lungs, and the extent defined in terms of dimensions.
diaphragm R L
other L “Other” includes calcification of the mediastinal and pericardial pleura.
extent 1 2 3 1 = an area of calcified pleura with greatest diameter up to about 20 mm
or a number of such areas the sum of whose greatest diameters
does not exceed about 20 mm.
2 = an area of calcified pleura with greatest diameter exceeding about
20 mm and up to about 100 mm, or a number of such areas the
sum of whose greatest diameters exceed about 20 mm but does
not exceed about 100 mm.
3 = an area of calcified pleura with greatest diameter exceeding about
100 mm or a number of such area whose sum of greatest diameters
Symbols exceeds about 100 mm.
It is to be taken that the definition of such of the Symbols is preceded
by an appropriate word or phrase such as “suspect” , “pneumoconiotic
changes suggestive of“, or “opacities suggestive of “, etc.
aa - atherosclerotic hi - enlargement of non-calcified hilar or mediastinal lymph nodes
at - significant apical pleural thickening ho - honeycomb lung
ax - coalescence of small opacities id - ill-defined diaphragm border
bu - bulla(e) ih - ill-defined heart border
ca - cancer: thoracic malignancies excluding mesothelioma kl - septal (Kerley) lines
- calcified non-pneumoconiotic nodules (e.g. granuloma) or
cg nodes me - mesothelioma
cn - calcification in small pneumoconiotic opacities pa - plate atelectasis
co - abnormality of cardiac size or shape pb - parenchymal bands
cp - cor pulmonale pi - pleural thickening of an interlobar fissure
cv - cavity px - pneumothorax
di - marked distortion of an intrathoracic structure ra - rounded atelactasis
ef - pleural effusion rp - rheumatoid pneumoconiosis
em - emphysema tb - tuberculosis
es - eggshell calcification of hilar or mediastinal lymph nodes od - other disease or significant abnormality
fr - fractured rib(s) (acute or healed)
Comments Presence YN Comments should be recorded pertaining to the classification of the radiograph particularly if some
other cause is thought to be responsible for a shadow.
3 CM-933 (Rev. April 2020)
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