3A. ANY PLEURAL ABNORMALITIES 

 CONSISTENT WITH PNEUMOCONIOSIS? YES Complete Sections NO Proceed to

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

3C. COSTOPHRENIC ANGLE OBLITERATION R L Proceed to

Section 3D NO Proceed toSection 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?

YES Complete NO Proceed to

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 OD (Specify od.) Date Personal Physician notified? 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)

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 

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. OMB No. 1240-0023

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?

 YES □ Proceed to Section 5 NO □ Complete Section 2A

2A. Any Parenchymal Abnormalities Consistent with Pneumoconiosis?

 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

q t q t 2/1 2/2 2/3 SIZE O A B C Proceed to 

 Section 3

r u r u 3/2 3/3 3/+

R L
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

CM-933 (Rev. April of 2020)

2

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
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

Acceptable, with no technical defect likely to impair classification of the radiograph for pneumoconiosis.

Acceptable, with some technical defect but still acceptable for classification 

purposes.

Unacceptable for classification purposes.

The category of profusion is based on the assessment of concentration 

of opacities by comparison with the standard radiographs.

Category 0 – small opacities absent or less profuse than the lower limit 

of Category 1.

Categories 1, 2 and 3 – represent increasing profusion of small opacities as defined by the corresponding standard radiographs. 

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) 

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.

The letters p, q, and r denote the presence of small rounded opacities. 

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. 

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.

2

Parenchymal 3

Abnormalities Small Opacities U/R

Profusion 0/- 0/0

1/0 1/1

2/1 2/2

3/2 3/3

0/1

1/2

2/3

3/+

Zones RU RM RL

LU LM LL

Shape and Size

rounded p/p q/q r/r

irregular s/s t/t u/u

p/s p/t p/u p/q p/r 

q/s 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

mixed

Large Opacities A B C 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

Pleural Thickening 

Chest Wall

Type 

Site

Category C – one or more opacities whose combined area exceed the equivalent of the right upper zone.

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 A B C 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 1 2 3 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 Y N 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 showing profusion subcategory 1/1 t/t.

If the thickening extends up the chest wall then both costophrenic 

angle obliteration and pleural thickening should be recorded.

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.

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 

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.

Costophrenic Angle Site 

Presence

R 

Y 

L 

N 

Pleural Calcification Site R L

Site 

chest wall diaphragm 

other

R 

R

L

L 

L

extent 1 2 3

Symbols

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

cg - calcified non-pneumoconiotic nodules (e.g. granuloma) or 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 Y N 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)