(01/2003) USDOL/OALJ BLBA Evidence Summary Page 1 of 7

UNITED STATES DEPARTMENT OF LABOR

OFFICE OF ADMINISTRATIVE LAW JUDGES

BLACK LUNG BENEFITS ACT

EVIDENCE SUMMARY FORM

Case Name :

Case No.:

Evidence submitted in support of position of: Claimant Employer Director (check one)

Signature of submitter: Address of submitter:

s/

^ Signature of Representative, Attorney, or Party

^ Printed Name of Representative, Attorney, or Party Phone: Fax:

Date of this submission:
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I. Chest x-ray evidence

A. Initial evidence. A party may submit no more than two chest x-ray interpretations in support of its

position. 20 C.F.R. § 725.414(a)(2)(i) and (3)(i) (2001).

Exhibit No. Physician

B-Reader (B)/

Board Cert. (BCR)

Date of 

X-ray study

Date of 

Reading Film Quality Reading

OWCP Evaluation. The Department is required to provide the miner with a chest x-ray study as part of the

complete pulmonary evaluation. 20 C.F.R. § 725.406(a) (2001).

B. Rehabilitative evidence is permitted ONLY if opposing party has presented a rereading which “tends to

undermine” a specific x-ray exhibit set forth above. In such a case, the proponent of the x-ray exhibit “shall

be entitled to submit an additional statement from the physician who originally interpreted the chest X-ray.” 

20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit No. Physician Date of Report

Rehabilitation

of Exhibit No. Comments

For use by the Director only. The Director may submit rehabilitative evidence if any party submits

evidence which “tends to undermine” the findings of the Department-sponsored chest x-ray study.

C. Rebuttal evidence. A party may offer no more than one physician’s interpretation of each chest x-ray

study submitted by opposing party. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit No. Physician

B-Reader (B)/

Board Cert. (BCR)

Date of 

X-ray study

Date of 

Reading Film Quality Reading

For rebuttal of Department-sponsored chest x-ray study only.
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II. Pulmonary function studies

A. Initial evidence. A party may submit the results of no more than two pulmonary function studies in

support of its position. 20 C.F.R. § 725.414(a)(2)(i) and (3)(i) (2001).

Exhibit

No. Physician

Date of

study

Tracings

present?

Flowvolume

loop?

Bronchodilator? FEV1FVC/

MVV

Coop. and

Comp.

Noted?

OWCP Evaluation. The Department is required to provide the miner with a pulmonary function study as

part of the complete pulmonary evaluation. 20 C.F.R. § 725.406(a)(2001).

B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which “tends to

undermine” a specific pulmonary function study exhibit set forth above. In such a case, the proponent of

the pulmonary function study exhibit “shall be entitled to submit an additional statement from the physician

who . . . administered the objective testing.” 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

 

Exhibit

No. Physician Date of Report

Rehabilitation

of Exhibit No. Comments

For use by the Director only. The Director may submit rehabilitative evidence if any party submits

evidence which “tends to undermine” the findings of the Department-sponsored pulmonary function study.

C. Rebuttal evidence. A party may offer no more than one physician’s assessment of each pulmonary

function study offered by the opposing party. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit

No. Physician Date of Report

 Rebuttal of 

Exhibit No. Comments

For rebuttal of Department-sponsored pulmonary function study only.
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III. Blood gas studies

A. Initial evidence. 

A party may submit the results of no more than two blood gas studies in support of its position. 20 C.F.R.

§ 725.414(a)(2)(i) and (3)(i) (2001).

Exhibit

No. Physician

Date of

Study Altitude

Resting(R)

Exercise(E) PCO2 PO2 Comments

OWCP Evaluation. The Department may provide the miner with a blood gas study as part of the complete

pulmonary evaluation. 20 C.F.R. § 725.406(a) (2001).

B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which “tends to

undermine” a specific blood gas study set forth above. In such a case, the proponent of the blood gas

study exhibit “shall be entitled to submit an additional statement from the physician who . . . administered

the objective testing.” 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit

No. Physician Date of Report

Rehabilitation

of Exhibit No. Comments

For use by the Director only. The Director may submit rehabilitative evidence if any party submits

evidence which “tends to undermine” the findings of the Department-sponsored blood gas study.

C. Rebuttal evidence. A party may offer no more than one physician’s assessment of each blood gas study

offered by the opposing party. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit

No. Physician Date of Report

 Rebuttal of 

Exhibit No. Comments

For rebuttal of Department-sponsored blood gas study only.
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IV. Medical reports

The parties are notified that “medical reports” may only be based on medical evidence which is admissible consistent with

the evidentiary limitations at 20 C.F.R. § 725.414(a)(2)(i), (3)(i), and (c) (2001). 20 C.F.R. §§ 725.414(a)(2)(i) and 725.457(d)

(2001). Medical reports are defined in the regulations as:

A physician’s written assessment of the miner’s respiratory or pulmonary condition. A medical report may

be prepared by the physician who examined the miner and/or reviewed the available admissible evidence. 

A physician’s written assessment of a single objective test, such as a chest X-ray or a pulmonary function

test, shall not be considered a medical report for purposes of this section.

20 C.F.R. § 725.414(a)(1) (2001). 

A. Initial evidence. A party may submit no more than two medical reports in support of its position. 20

C.F.R. § 725.414(a)(2)(i) and (3)(i) (2001).

Exhibit No. Physician

Date of

Medical Report Comments

OWCP Evaluation. The Department is required to provide the miner with a complete pulmonary evaluation. 

20 C.F.R. § 725.406(a) (2001).

B. Rehabilitative evidence is permitted ONLY if opposing party has presented “rebuttal evidence” which

“tends to undermine” the conclusion of a physician who prepared one of the above-listed medical reports. It

is noted that “rebuttal evidence” may consist of “no more than one physician’s interpretation of each chest

X-ray, pulmonary function test, blood gas study, autopsy or biopsy” submitted by the opposing party. In

such a case, the proponent is entitled to submit an “additional statement” from the physician who prepared

the medical report explaining his or her conclusion in light of the rebuttal evidence. 20 C.F.R. §

725.414(a)(2)(ii) and (3)(ii) (2001). 

Exhibit No. Physician

Date of

Report

Rehabilitation

of Exhibit No. Comments

For use by the Director only. The Director may submit rehabilitative evidence if any party submits

evidence which “tends to undermine” the findings of the Department-sponsored medical opinion. 
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V. Autopsy evidence

A. Initial evidence. A party may submit no more than one autopsy report in support of its position. 20

C.F.R. § 725.414(a)(2)(i) and (3)(i) (2001).

Exhibit

No. Physician

Date of

Autopsy Report Comments

B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which “tends to

undermine” the autopsy report. In such a case, the proponent of the report shall be entitled to submit an

“additional statement” from the physician who prepared the autopsy report explaining his or her conclusions

in light of the rebuttal evidence. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit

No. Physician Date of Report

Rehabilitation

of Exhibit No. Comments

C. Rebuttal evidence. A party may offer no more than one physician’s interpretation of the opposing party’s

autopsy report. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit

No. Physician Date of Report

Rebuttal of

Report Dated: Comments

VI. Biopsy evidence

A. Initial evidence. A party may submit no more than one report of each biopsy in support of its position. 

20 C.F.R. § 725.414(a)(2)(i) and (3)(i) (2001).

Exhibit

No.

Physician Date of Biopsy

Report 

Comments

B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which “tends to

undermine” a particular biopsy report. In such a case, the proponent of the report shall be entitled to submit

an “additional statement” from the physician who prepared the biopsy report explaining his or her

conclusions in light of the rebuttal evidence. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit

No. Physician Date of Report

Rehabilitation

of Exhibit No. Comments

C. Rebuttal evidence. A party may offer no more than one physician’s interpretation of each biopsy report

submitted by the opposing party. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit

No. Physician Date of Report

Rebuttal of

Report Dated: Comments
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VII. “Other medical evidence” under § 718.107

A. Initial evidence. A party may submit “other medical evidence” under § 718.107, such as CT-scans, and

“[t]he party submitting the test or procedure . . . bears the burden to demonstrate that the test or procedure

is medically acceptable and relevant to establishing or refuting a claimant’s entitlement to benefits.” 20

C.F.R. § 718.107(b) (2001). 

Exhibit

No. Physician Type of Record

Date of

Activity Comments

B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which “tends to

undermine” a specific test or study set forth above. In such a case, the proponent of the study or test “shall

be entitled to submit an additional statement from the physician who . . . administered the objective

testing.” 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit

No. Physician Date of Report

Rehabilitation

of Exhibit No. Comments

C. Rebuttal evidence. A party may offer no more than one physician’s assessment of each test or study

offered by the opposing party. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).

Exhibit

No. Physician Date of Report

Rebuttal of

Exhibit No. Comments

VIII. Hospitalization records and treatment notes

The amended regulations provide that, notwithstanding the evidentiary limitations contained at 20 C.F.R. § 725.414(a)(2) and

(a)(3), “any record of a miner’s hospitalization for a respiratory or pulmonary or related disease may be received into

evidence.” 20 C.F.R. § 725.414(a)(4) (2001).

Exhibit

No.

Beginning and Ending Dates of

Hospitalization/

Treatment

Name of

Hospital/Physician Nature of Treatment