Roetgenographic Interpretation Form. This is a Official Federal Forms form and can be use in US Dept Of Labor.
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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 Ƒ Proceed to Section 5 NO DAY 2 3 U/R YR 2A. Any Parenchymal Abnormalities Consistent with Pneumoconiosis? Ƒ Complete Section 2A YES Ƒ Complete 2B and 2C 2B. Small Opacities Consistent With Pneumoconiosis NO Ƒ Proceed to Section 3 2C. Large Opacities Consistent With Pneumoconiosis a. SHAPE/SIZE c. PROFUSION PRIMARY SECONDARY p s p q t r u b. ZONES 0/- 0/0 0/1 s 1/0 1/1 1/2 q t 2/1 2/2 2/3 r u 3/2 3/3 3/+ R O SIZE A B Proceed to Section 3 C L 3A. ANY PLEURAL ABNORMALITIES CONSISTENT WITH PNEUMOCONIOSIS? 3B. PLEURAL PLAQUES Chest Wall In Profile O Site R 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 (mark site, calcification, extent and width) Calcification O R L L Face On O R L O R L Diaphragm O R L O R L O R Other site(s) O R L O R L 1 2 3C. COSTOPHRENIC ANGLE OBLITERATION R Site O 1 2 > 10 mm = c L 3 O R a 3 b Proceed to Section 3D L Proceed to Section 4A NO Width (in profile only) (3mm minimum width required) 3 to 5 mm = a 5 to 10 mm = b > 1/2 of lateral chest wall = 3 O L a c b c Proceed to Section 4A NO 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 3D. DIFFUSE PLEURAL THICKENING (mark site, calcification, extent, and width) Chest wall Complete Sections 3B, 3C YES Width (in profile only) (3m minimum width required) 3 to 5 mm = a 5 to 10 mm = b > 10 mm = c O R a b Extent (chest wall, combined for in profile and face on) Calcification In Profile O R L O R L O R Face On O R L O R L 1 2 O L 1 3 2 3 O L a c b c 4A. ANY OTHER ABNORMALITIES? Complete 4B and 4C YES Proceed to Section 5 NO 4B. OTHER SYMBOLS (OBLIGATORY) aa at ax bu REPORT ITEMS WHICH MAY BE OF PRESENT CLINICAL SIGNIFICANCE IN THIS SECTION OTHER COMMENTS 4C ca cg cn co cp cv di (Specify od.) OD ef em es fr hi ho id ih kl me Date Personal Physician notified? pb M SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 4C? 5A. pa YES pi o. NO px D ra rp ay tb Y r. Proceed to Section 5 FACILITY PROVIDING ROENTGENOGRAPHIC EXAMINATION: DOL Medical Provider Number (if applicable): Ƒ Yes Ƒ Was film taken by a registered radiographer/radiographic technologist? No State Name Registration No. 5B. Physician Interpreting Film (Print Name): ___________________________________________________________________________________ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ 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 the profusion as a whole over the affected zones of the lung and by comparing this with the standard radiographs. The letters p, q, and r denote the presence of small rounded opacities. Three sizes are defined by the appearances on standard radiographs. p/p q/q r/r mixed Large Opacities p/s p/t p/u p/q p/r q/w q/t q/u q/p q/r r/s r/t r/u r/p r/q s/p s/q s/r s/t s/u t/p t/q t/r t/s t/u u/p u/q u/r u/s u/t ABC irregular p = diameter up to about 1.5 mm. q = diameter exceeding about 1.5 mm and up to about 3 mm. 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. s = width up to about 1.5 mm. t = width exceeding about 1.5 mm and up to about 3 mm. u = width exceeding 3 mm and up to about 10 mm. 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. The categories are defined in terms of dimensions of the opacities. s/s t/t u/u 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 Pleural Thickening Chest Wall Category C – one or more opacities whose combined area does not exceed the equivalent of the right upper zone. Type Site R Width Two types of pleural thickening of the chest wall are recognized: circumscribed (plaques) and diffuse. Both types may occur together. Pleural thickening of the chest wall is recorded separately for the right (R) and left (L) thorax. 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. L ABC 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 Extent 1 2 3 Diaphragm Presence Y Site Presence R Y Site R L Site chest wall diaphragm other R R R L L L extent 1 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 A plaque involving the diaphragmatic pleura is recorded as present (Y) or absent (N) separately for the right (R) or left (L) thorax. The presence (Y) or absence (N) costophrenic angle obliteration is 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. If the thickening extends up the chest wall then both costophrenic angle obliteration and pleural thickening should be recorded. L N Pleural Calcification 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. N Costophrenic Angle 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 can not usually be measured. 2 The site and extent of pleural calcification are recorded separately for the two lungs, and the extent defined in terms of dimensions. “Other” includes calcification of the mediastinal and pericardial pleura. 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. 3 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 dies 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 exceeds about 100 mm. Symbols 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 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 od - atherosclerotic - significant apical pleural thickening - coalescence of small pneumoconiotic opacities - bulla(e) - cancer of lung or pleura - calcified non-pneumoconiotic opacities - calcification in small pneumoconiotic opacities - abnormality of cardiac size or shape - cor pulmonale - cavity - marked distortion of the intrathoracic organs - effusion - definite emphysema - eggshell calcification of hilar or mediastinal lymph nodes - fractured rib(s) (acute or healed) Comments Presence Y N - enlargement of hilar or mediastinal lymph nodes - honeycomb lung - ill defined diaphragm - ill defined heart outline - septal (kerley) lines - mesothelioma - plate atelectasis - parenchymal bands - pleural thickening in the interlobar fissue - pneumothorax - rounded atelactasis - rheumatoid pneumoconiosis - tuberculosis - other significant abnormality Comments should be recorded pertaining to the classification of the radiograph particularly if some other cause is thought to be responsible for a shadow. American LegalNet, Inc. www.FormsWorkFlow.com CM-933 PAGE 2(Rev. 01-11)