Physicians Roentgenographic Interpretation Report of Occupational Pneumoconiosis
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Physicians Roentgenographic Interpretation Report of Occupational Pneumoconiosis Form. This is a West Virginia form and can be use in Workers Comp.
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Tags: Physicians Roentgenographic Interpretation Report of Occupational Pneumoconiosis, BI-206, West Virginia Workers Comp,
BI-206
01/06
Please return completed form to:
BrickStreet Mutual Insurance
Occupational Pneumoconiosis Unit
P.O. Box 3151
Charleston, WV 25332-3151
Physician's Roentgenographic
Interpretation Report of
Occupational Pneumoconiosis
Claimant Name:
Claim Number:
Claimant’s Social Security Number:
Type of Reading:
Facility Identification:
A
1a. Date of X-Ray (mm/dd/yyyy)
1b. Film Quality
1
2
B
P
If not grade L give reason:
3
2a. Any Parenchymal Abnormalities consistent with pneumoconiosis?
Yes (Complete 2b and 2c)
2b. Small Opacities
a. Shape / Size
No Proceed to Section 3
b. Zones
Primary
1C. Is Film Completely Negative?
Yes (Go to Section 5)
No (Go to Section 2)
U/R
Secondary
c. Profusion
R
2c. Large Opacities
Size
0/1
L
0/0
0/1
P
S
P
S
1/0
1/1
T
Q
T
2/1
2/2
U
R
U
3/2
3/3
3/4
3a. Any Pleural Abnormalities consistent with pneumoconiosis?
Yes (Complete 3b, 3c, 3d)
3b. Pleural Thickening
C o m p le t e i n b l u e o r b l ac k i n k.
B
C
2/3
R
A
1/2
Q
O
a. Circumscribed (plaque)
Site
Site In
Profile
O
R
i. Width
O
A
B
ii. Extent
O
1
2
Proceed to Section 4a
3c. Pleural Thickening…..Chest Wall
a. Diaphragm (plaque)
No
Proceed to Section 3a
O
R
L
b. Costophrenic Angle
Site
O
R
L
b. Diffuse
Site In
Profile
O
C
O
A
B
3
O
1
O
R
C
i. Width
O
A
B
3
ii. Extent
O
1
3
Face On
iii. Extent
O
1
L
2
Face On
iii. Extent
O
1
2
3
O
1
2
O
L
C
O
A
B
C
2
3
O
1
2
3
2
3
O
1
2
3
3d. Pleural Calcification
Site
O
R
Extent
a. Diaphragm
b. Wall
O
O
1
1
c. Other sites
O
1
4a. Any other abnormalities?
Site
O
2
2
3
3
2
3
L
a. Diagram
b. Wall
c. Other Sites
Yes Complete 4b and 4c
Extent
O
O
1
1
2
2
3
3
O
1
2
3
No Proceed to Section 5a
4b. Other Symbols (obligatory)
O
AX
BU
CA
Report items which may be of present
clinical significance in this section.
CN
CO
CP
CW
DI
EF
EM
ES
FR
HI
HO
ID
IH
KL
PI
PX
RP
TB
Date personal physician notified
OD
4c. Other Comments:
Should the worker see a personal physician because of comments in Section 4c?
5a. Film Reader’s Initials
Physician’s Signature
Yes
Physician’s Social Security #
No
Proceed to Section 5a
Date of Reading
Date
BrickStreet Mutual Insurance
P.O. Box 3151
Charleston, WV
25332-3151
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