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- - CHEST RADIOGRAPH CLASSIFICATION DATE OF RADIOGRAPH (mP-dG-\\\\) 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 Underinflation 1. IMAGE QUALITY Mottle Excessive Edge Enhancement Other (please specify) 2A. ANY CLASSIFIABLE PARENCHYMAL ABNORMALITIES? YES NO Complete Sections 2B and 2C Proceed to Section 3A SMALL OPACITIES 2B. 0/- 0/0 0/1 1/1 1/2 1/0 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 t q r u PRIMARY SECONDARY p s t q r u LARGE OPACITIES Proceed to Section 3A 2C. SIZE O A B C ANY CLASSIFIABLE PLEURAL ABNORMALITIES? 3A. 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 1 2 3 3 O R O L a b a b c (mark site, calcification, extent, and width) c COSTOPHRENIC ANGLE OBLITERATION 3C. 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 ANY OTHER ABNORMALITIES? 4A. YES Complete Sections 4B-E and 5. Complete Section 5. NO - 5. NIOSH Reader ID PRINTED NAME (LAST, FIRST MIDDLE) STREET ADDRESS STATE ZIP CODE CITY 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
- - 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 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/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS H21-8, Atlanta, GA 30333, ATTN: PRA (0920-0020). Do not send the completed form to this address.