Medical History and Examination for 

Coal Mine Workers’ Pneumoconiosis 

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 receive a benefit. The results of this examination will aid in 

determining the miner’s eligibility for black lung benefits. The method of collecting information complies with the Freedom of Information Act, 

the Privacy Act of 1974, and OMB Cir. No. 108. 

A. Patient Information (Please type or neatly print all responses.) OMB No.:1240-0023 

1. Name and Address 2. DOL's Case ID Number Expires: 11/30/2026

3. Telephone Number

4. Date of Exam 

5. Date of Birth 

6. Personal Physician (name, address, phone number)

Phone:

7. Examining Physician (name, address, phone number)

Phone:

B. Employment History (Please type or neatly print all responses.) 

“Employment History,” Form CM-911a or equivalent (dated ) is attached. Please review the form and, with the 

miner’s help, complete block 1.a, below describing his / her most recent coal mine job of at least one year’s duration. 

Also complete block 1.d. (personal protective equipment). Then, move on to “C. Patient History.” 

CM-911a is not attached – complete both sections 1. and 2. below.

1. Coal Mine Employment – CME. List most recent employers first. In line (a.) describe the last job of at least one year’s 

 duration and specify the exertional level of the job. (Include in all lines any coal mine construction or transportation work, 

 or work in a mine preparation facility.

Name of Company Job Title and Description of Job's Physical Requirements From 

(mm/yyyy)

To 

(mm/yyyy)

a. Last CME held at least one year: Title:

Description of physical requirements:

Level of exertion: Light Moderate Heavy Very heavy

b. Other CME:

c. Additional number of years in CME not described above: years

d. Did the miner regularly use personal protective equipment? 

 If yes, what type of personal protective equipment did the miner use?

Yes No

2. Other Employment – Not CME. (If the employment exposed the claimant to an occupational toxic inhalant hazard, describe the 

 inhalant under “Job Title and Description.”)

Name of Company Job Title and Description From 

(mm/yyyy)

To 

(mm/yyyy)
C. Patient History (Family – Medical – Social) (Please type or neatly print all responses.) 

1. Family History. 

 Have the patient's parents, children, or other "blood" relatives ever had any of the following? (Check all that apply):

High Blood 

Pressure

Heart TB Asthma Allergies Emphysema Stroke Diabetes

Disease

Mother

Father

Siblings

Children

2. Individual Health/Medical History

a. Does the patient have a history of :

Yes No When Manifested (mm/yy)

Frequent Colds

Pneumonia

Pleurisy

Attacks of wheezing

Tuberculosis

Chronic Bronchitis

Bronchial Asthma

Histoplasmosis

Emphysema

Stroke

Yes No When Manifested (mm/yy)

Arthritis

Heart Disease/Problems

Allergies

Cancer (of )

Diabetes Mellitus

High Blood Pressure

Connective Tissue Disease

Other

Other

Other

b. Other Significant Conditions or Serious Illnesses (and when they were diagnosed):

c. Hospitalizations (reasons and dates):

d. Surgeries:

3. Social History

a. Smoking History: Never smoked

Smoked intermittently Has stopped smoking Currently smoking

Started:

Stopped:

Smoked what?

How much?

(e.g., packs/day)

Started:

Stopped:

Smoked what?

How much?

(e.g., packs/day)

Started:

Smokes what?

How much?

(e.g., packs/day)

b. Other Pertinent Social History (e.g. drug or alcohol use, strenuous hobbies):
D. Present Illnesses / Physical Examination (Please type or neatly print all responses.) 

1. Chief Complaints/Symptoms - as described by patient. Please comment on all "Yes" answers (e.g., describe frequency, duration, and/or 

severity of symptoms).

Yes No Comments

Sputum (daily?)

Wheezing (daily?)

Dyspnea (quantitate)

Cough

Hemoptysis

Chest pain (inciting factor)

Orthopnea

Ankle edema

Paroxysmal Nocturnal Dyspnea

Other

(Indicate in D.4., below, any of the above symptoms manifested during the exam.)

2. Other Complaints. (Include here the patient's description of any limitations in physical activities like walking, 

climbing, and lifting.)

3. Current Treatment (including medications):

4. Physical Findings: Based on your physical examination, provide a narrative statement listing all findings, 

especially those pertinent to the respiratory/pulmonary system and the cardiovascular system.

Weight:

Findings (including respiratory/pulmonary symptoms):

Height: (in inches and in stocking feet – no shoes)

(lbs.)
5. Summary of Diagnostic Testing - in the space below, check the applicable block(s) next to any test results (including those 

conducted in conjunction with this physical exam) which you reviewed and relied upon, at least in part, in reaching your medical 

assessments and conclusions - especially those on the next page. Be sure to show the date(s) of each test and summarize the results.

Dates Summary of Results

Chest X-ray

Vent Study (PFS)

Arterial Blood Gas

Other

Other

6. Respiratory/Pulmonary Diagnosis(es): Identify the patient’s chronic respiratory/pulmonary disease(s) or condition 

(s). Do not address the etiology of any diagnosed condition here; instead, address etiology in Section 7 below.

6a. Explain how you arrived at your diagnosis(es) in D.6. above. In particular, explain how the results of the 

diagnostic tests listed in D.5. above relate to your diagnosis(es). Attach additional sheets if necessary.

7. Etiology of Respiratory/Pulmonary Diagnosis(es): Describe the cause(s) of each respiratory/pulmonary diagnosis 

listed above; possible causes include occupational or environmental exposure, genetic predisposition, smoking, 

other, or unknown. In particular, describe the contribution of the patient’s occupational dust exposure to his/her 

disease or condition. Explain how you arrived at your conclusion, including how the diagnostic tests listed in D.5. 

above relate to your opinion. Attach additional sheets if necessary. 

8. Disability/Impairment and Cause: If the patient has chronic respiratory/pulmonary disease or condition, give your 

medical assessment on the following:

8a. Describe the degree of severity of the patient’s respiratory/pulmonary impairment, particularly in terms of the 

extent to which the impairment prevents the patient from performing his/her current or last coal mine job of one 

year’s duration (refer to Section B.1.a.) This is considered the miner’s disability assessment. Attach additional 

sheets if necessary.
8b. Explain how you arrived at your disability assessment. In particular, explain how the results of the diagnostic 

tests listed in D.5. above relate to your conclusion. Attach additional sheets if necessary.

8c. If the patient has a respiratory/pulmonary disability or impairment, identify the cause(s) of the disability or 

impairment, especially with reference to the diagnoses listed in D.6. above. If there is more than one cause, give 

your estimate of the percentage or portion of impairment that can be attributed to each diagnosis (e.g. 50%, 

substantial, minimal, etc.). Explain how you reached your conclusions. Attach additional sheets if necessary.

9. Non-pulmonary Diagnosis: If the patient has any cardiac or other non-respiratory/pulmonary condition(s), 

indicate what the condition is and describe its impact on the patient’s respiratory/pulmonary condition or impairment 

(if any), especially as it may affect his/her ability to perform coal mine work.

E. Physician Referral

Should the patient be referred to another physician for further evaluation? Y N Has referral been made Y N

For what reason?

F. Physician's Signature

I certify that the information furnished is correct and that I am aware my signature attests to its accuracy. I am also 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 imprisonment for up to one year, or both.

Signature: Date:

(Physician's name should be typewritten on the front page of this form.)

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: U.S. Department of Labor, OWCP/DCMWC, PO Box 8307, London, KY 40742-8307 

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

Public Burden Statement 

We estimate that it will take an average of 40 minutes per response to complete this information collection, including the time for reviewing instructions, searching existing data 

sources, gathering and maintaining the data needed, and composing and reviewing the collection of information. If you have any comments regarding this burden estimate or any 

other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor, Division of Coal Mine Workers' 

Compensation, 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 complete this collection of information unless it displays a currently valid OMB control number. 
INSTRUCTIONS FOR BLACK LUNG PHYSICAL EXAMINATION 

(GUIDE TO COMPLETING FORM CM-988) 

The enclosed Form CM-988, “Medical History and Examination for Coal Mine Workers' 

Pneumoconiosis,” is used by the U.S. Department of Labor to obtain the examining physician's 

findings with respect to the existence, severity, and cause of the miner's chronic respiratory or 

pulmonary disease, if any. The physical examination is part of a complete pulmonary evaluation 

that usually includes a chest x-ray, pulmonary functions study, and arterial blood gas test. Please 

note that this is a new form, replacing the previous version of the CM-988. There have been a 

number of minor revisions. It is important that you provide a response to each question or item in 

each section of the form, even if the only appropriate response is “N/A” (Not Applicable). Also, 

please pay close attention to: 

Block B.1. Coal Mine Employment - CME. 

Because total disability is defined as the miner's inability to perform his or her usual coal mine job 

(usually the miner's most recent job of at least one-year's duration), the examining physician must 

understand the physical requirements of the miner's coal mine employment. You must record the 

job title and describe the specific physical requirements of the miner's last coal mine job held for at 

least one year on Block B.1.a. In addition, we will provide you with Form CM-911a, “Employment 

History,” whenever possible. This form contains the miner's own account of his or her work history 

and is provided to assist you in making an informed medical evaluation. Only Blocks B.1.a. and 

B.1.d. need to be completed when we have provided you with the “Employment History” form. If 

we do not provide the “Employment History” form, and it is not available from the Black Lung 

District Office that authorized this examination, you must obtain a brief work history from the miner 

for entry in Blocks B.1. and B.2. 

Block D.4. Physical Findings. 

Please concentrate on reporting findings that may be relevant to the patient's respiratory/

pulmonary ability to perform his or her last coal mine work. Note any general findings you believe 

are important, such as blood pressure, temperature, and pulse. Also note any specific findings 

about the miner's extremities, thorax and lungs, heart, ENT, musculoskeletal structure, and 

abdomen that are relevant to your evaluation. 

Block D.6.a. Respiratory/Pulmonary Diagnosis(es). 

If you find that the patient has pneumoconiosis or any other respiratory/pulmonary condition, it is 

essential that you document the facts you have used to make this diagnosis. Please include 

relevant supporting information from the history, physical examination, chest imaging, and 

physiologic testing, as specifically requested. Your narrative should provide a complete rationale 

as to why you are diagnosing pneumoconiosis, particularly if your diagnosis is not clearly 

supported by the test results from Block D.5. 

Block D.7. Etiology of Respiratory/Pulmonary Diagnosis(es). 

Please describe the causes of each respiratory/pulmonary diagnosis above. Causes could include 

occupational or environmental exposures, genetic predisposition, personal habits, infectious 

agents, unknown, etc. 
Please support your conclusion by citing the information obtained in your exam including exposure 

history, social history (e.g. smoking), chest imaging, test results and physical examination findings. 

Please describe the contribution of the miner's occupational dust exposure to his or her 

respiratory/pulmonary condition. 

Note that the Department of Labor's regulations define pneumoconiosis not only as one of the lung 

diseases recognized by the medical community as pneumoconiosis, but also as any chronic 

respiratory/pulmonary disease or impairment significantly related to, or substantially aggravated 

by, dust exposure in coal mine employment. This definition includes such diseases as chronic 

obstructive pulmonary disease (COPD), emphysema, and chronic bronchitis when they arise out of 

coal mine employment. 

Block D.8. Disability/Impairment and Cause. 

a. Please describe the severity of any respiratory/pulmonary impairment that you diagnose. This 

impairment must then be compared to the exertional requirements of the miner's last coal mine 

job. You must reach one of two conclusions: (1) The patient is totally disabled for this last coal 

mine job due to the respiratory/pulmonary condition, or (2) he or she is not totally disabled and 

has the respiratory/pulmonary capacity to perform all the physical requirements of his or her last 

coal mine job. Do not simply diagnose a “mild,” “moderate,” or “severe” impairment, or cite the 

AMA Guides to Impairment class (e.g., Class 0-4) alone. You must also provide your reasoned 

opinion regarding whether the patient is able to perform the duties required in his or her last coal 

mine job. 

b. Please explain your disability assessment with reference to the results of your examination and 

testing. In addition, if the miner's objective test results do not “qualify” to demonstrate total 

disability under the Department's pulmonary function or blood gas study guidelines, but you 

nevertheless diagnose total respiratory/pulmonary disability, please explain. 

c. If you diagnose a respiratory/pulmonary disability, identify the cause(s) of the disability, including 

pulmonary or non-pulmonary causes. Please report the extent to which each of the diagnoses you 

listed in D.6. contributes to the miner's disability. You may use percentages, proportions, or 

narrative, but please be thorough and ensure that you have weighed the contribution of each 

diagnosis to the disability. Include citations for any other sources you used in reaching your 

conclusions. 

Block D.9. Non-pulmonary diagnosis. 

Please report any cardiac or other diagnosis that may affect the miner's exertional ability from a 

respiratory standpoint. Be sure to state the degree of impairment, if any, and explain if the 

symptoms are similar to those of a respiratory/pulmonary diagnosis. 

This form should be completed thoroughly to avoid the necessity of follow-up questions. 

Please note that the examination report form CM-988 is available in electronic, fillable PDF format 

from the DCMWC website at https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-988.

pdf. You may file the completed form through DCMWC's C.O.A.L. Mine web portal at 

https://coalmine.dol.gov or by mailing it to: 

U.S. Department of Labor 

OWCP/DCMWC 

PO Box 8307 

London, KY 40742-8307