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                        OMB No. 1240-0023
determining the miner’s eligibility for black lung benefits. This method of collecting information complies with the Freedom of                        Expires: 11/30/2026
Information Act, the Privacy Act of 1974, and OMB Cir. No. 108.

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?                                                           Complete                                       Proceed to
                                                             YES                                               NO
                                                                                       2B and 2C                                      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                            (Specify od.)                                   Date Personal Physician notified?
MAY BE OF PRESENT                OD                                                                                                            Mo.          Day        Yr.
CLINICAL SIGNIFICANCE
IN THIS SECTION
2C. OTHER COMMENTS


2D. SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 2C?                                                                          Proceed to Section 3
                                                                                                                         Yes         No


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:
  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 40743-8307
      For Further Information call TOLL FREE: 1-800-347-2502




                                                                                                                                      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,
   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-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                   -    Good
              2                   -    Acceptable, with no technical defect likely to impair classification of the radiograph for
                                       pneumoconiosis
              3                   -    Acceptable, with some technical defect but still acceptable for classification purposes.
             U/R                  -    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                   -    atherosclerotic aorta
             at                   -    significant apical pleural thickening
             ax                   -    coalescence of small opacities
             bu                   -    bulla(e)
             ca                   -    cancer: thoracic malignancies excluding mesothelioma
             cg                   -    calcified non-pneumoconiotic nodules (e.g granuloma) or nodes
             cn                   -    calcification in small pneumoconiotic opacities
             co                   -    abnormality of cardiac size or shape
             cp                   -    cor pulmonale
             cv                   -    cavity
              di                  -    marked distortion of the intrathoracic structure
             ef                   -    pleural effusion
             em                   -    emphysema
             es                   -    eggshell calcification of hilar or mediastinal lymph nodes
              fr                  -    fractured rib(s) (acute or healed)
              hi                  -    enlargement of non-calcified hilar or mediastinal lymph nodes
             ho                   -    honeycomb lung
              id                  -    ill-defined diaphragm border
              ih                  -    ill-defined heart border
              kl                  -    septal (Kerley) lines
             me                   -    mesothelioma
             pa                   -    plate atelectasis
             pb                   -    parenchymal bands
              pi                  -    pleural thickening in the interlobar fissure
             px                   -    pneumothorax
             ra                   -    rounded atelectasis
             rp                   -    rheumatoid pneumoconiosis
             tb                   -    tuberculosis
             od                   -    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)