- -

 

 

 

 

 

 

 

 

 

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

EXAMINEE'S Social Security Number 

FACILITY Number - Unit Number

Full SSN is optional, last 4 digits are required.

FEDERAL MINE SAFETY AND HEALTH ACT OF 1977

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL & PREVENTION

Coal Workers' Health Surveillance Program

National Institute for Occupational Safety and Health 

1000 Frederick Lane, MS LB208

Morgantown, WV 26508

FAX: 304-285-6058

- EXAMINEE'S Name (Last, First MI)

TYPE OF READING

A B F

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.

(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 

1. IMAGE QUALITY Underinflation

Mottle

Excessive Edge

Enhancement

Other (please specify)

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 Complete Sections 4B-E and 5. 

NO Complete Section 5.

-

5. NIOSH Reader ID

PRINTED NAME (LAST, FIRST MIDDLE)

STREET ADDRESS CITY STATE ZIP CODE 

SIGNATURE

-

 READER'S INITIALS DATE OF READING (mm-dd-yyyy)

(Leave ID Number blank if you are not a NIOSH A or B Reader)

Scapula Overlay

Form Approved 

OMB No.: 0920-0020 
 

 

 

 

 

 


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	


	

 


	


	


	


	


	


	


	


	


	


	


	


	


	

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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EXAMINEE'S Name (Last, First MI)

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

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

4E. Should worker see personal physician because of findings?

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

YES NO 

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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 D-74, Atlanta, GA 30333, ATTN: PRA (0920-0020). Do not send the completed form to this address.