FEDERAL MINE SAFETY AND HEALTH ACT OF 1977

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

DATE OF RADIOGRAPH (mP-dG-\\\\)

CENTERS FOR DISEASE CONTROL & PREVENTION 

Coal Workers' Health Surveillance Program

National Institute for Occupational Safety and Health 

1095 Willowdale Road, MS LB208

Morgantown, WV 26505

EXAMINEE'S Social Security Number 

CHEST RADIOGRAPH CLASSIFICATION

TYPE OF READING 

Note: Please record your interpretation of a single radiograph by placing an "x" in the appropriate boxes on this form. Classify all appearances described in the ILO 

International Classification of Radiographs of Pneumoconiosis or Illustrated by the ILO Standard Radiographs. Use symbols and record comments as appropriate.

A B F

OMB No.: 0920-0020

FACILITY ID#

(If not Grade 1, mark all 

boxes that apply) 

1 2 3 U/R 

Overexposed (dark) 

Underexposed (light) 

Artifacts 

Improper position 

Poor contrast 

Poor processing 

Underinflation 

Mottle 

Other (please specify) 

1. IMAGE QUALITY

2A. ANY CLASSIFIABLE PARENCHYMAL ABNORMALITIES?

YES NO Complete Sections 

2B and 2C 

Proceed to 

Section 3A 

2B. SMALL OPACITIES 

0/- 0/0 0/1 

1/0 1/1 1/2 

2/1 2/2 2/3 

3/2 3/3 3/+ 

c. PROFUSION 

UPPER 

MIDDLE 

LOWER 

R L 

b. ZONES a. SHAPE/SIZE 

p s 

q t

r u 

PRIMARY SECONDARY 

p s 

q t

r u 

LARGE OPACITIES 

Proceed to 

Section 3A 

2C. 

SIZE O A B C 

3A. ANY CLASSIFIABLE PLEURAL ABNORMALITIES?

YES NO Complete Sections 

3B, 3C 

Proceed to 

Section 4A 

3B. PLEURAL PLAQUES 

Chest wall 

In profile 

Face on 

Diaphragm 

Other site(s) 

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 

> 1/2 of lateral chest wall = 3 

Width (in profile only) 

3 to 5 mm = a 

5 to 10 mm = b 

> 10 mm = c 

(3mm minimum width required) 

Calcification 

O 

O 

O 

O 

R L 

R 

R 

R 

L 

L 

L 

Site 

O 

O 

O 

O 

R L 

R 

R 

R 

L 

L 

L 

O R O L 

1 2 3 1 2 3 

O R O L 

a b c a b

(mark site, calcification, extent, and width) 

c 

3C. COSTOPHRENIC ANGLE OBLITERATION Proceed to 

Section 3D R L NO Proceed to 

Section 4A 

3D. DIFFUSE PLEURAL THICKENING 

Chest wall 

In profile 

Face on 

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 

> 1/2 of lateral chest wall = 3 

Width (in profile only) 

3 to 5 mm = a 

5 to 10 mm = b 

> 10 mm = c 

(3mm minimum width required) 

Site 

O R L 

O R L 

O R O L 

1 2 3 1 2 3 

O R O L 

a b c a b c 

(mark site, calcification, 

extent, and width) 

Calcification 

O 

O 

R 

R 

L 

L 

4A. ANY OTHER ABNORMALITIES? YES NO Complete Sections 

4B, 4C, 4D, 4E 

Proceed to 

Section 5 

4B. OTHER SYMBOLS (OBLIGATORY) 

4E. 

OD If other diseases or significant abnormalities (OD), findings must be recorded on reverse. (section 4C/4D) 

Should worker see personal physician because of findings in section 4? YES NO 

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

Proceed to Section 5 

CDC/NIOSH (M) 2.8 

REV. 12/2013

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4C. MARK ALL BOXES THAT APPLY: (Use of this list is intended to reduce handwritten comments and is optional) 

Abnormalities of the Diaphragm 

Eventration
	

Hiatal hernia
	

Airway Disorders 

Bronchovascular markings, heavy or increased 

Hyperinflation 

Bony Abnormalities 

Bony chest cage abnormality
	

Fracture, healed (non-rib)
	

Fracture, not healed (non-rib)
	

Scoliosis
	

Vertebral column abnormality
	

4D. OTHER COMMENTS 

Lung Parenchymal Abnormalities 

Azygos lobe
	

Density, lung
	

Infiltrate
	

Nodule, nodular lesion
	

Miscellaneous Abnormalities 

Foreign body 

Post-surgical changes/sternal wire 

Cyst 

Vascular Disorders 

Aorta, anomaly of
	

Vascular abnormality
	

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may 

not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. 

Send comments regarding this burden estimate or any other aspect of this collection information, including suggestings for reducing this burden to CDC, 

Project Clearance Officer, 1600 Clifton Road, MS E-11, Atlanta, GA 30333, ATTN: PRA (09020-0020). Do not send the completed form to this address. 

5. PHYSICIAN'S Social Security Number* * Furnishing your social security 

number is voluntary. Your refusal 

to provide this number will not 

affect your right to participate in 

this program. 

PRINTED NAME (LAST, FIRST MIDDLE)

STREET ADDRESS CITY STATE ZIP CODE 

SIGNATURE

 READER'S 

INITIALS DATE OF READING (Pm-dG-\\\\)

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