Worker's Name Enter Worker's Name DATE OF RADIOGRAPH

MONTH DAY YEAR

Is Film Normal?
form from chest-ray.com

TYPE OF READING

$
A B C

1. FILM QUALITY

Overexposed (dark) Underexposed (light) Artifacts

Improper position Poor contrast Poor processing

Underinflation Mottle Other (please specify)

If not Grade 1, mark all boxes that apply

2A. ANY PARENCHYMAL ABNORMALITES CONSISTENT WITH PNEUMOCONIOSIS? 2B. SMALL OPACITIES

YES

Complete Sections 2B and 2C

NO

Proceed to Section 3A

2C. LARGE OPACITIES

c. PROFUSION b. ZONES

a. SHAPE/SIZE PRIMARY SECONDARY

R
UPPER MIDDLE LOWER

0 1 2 3

0 0 1 1 2 2 3 3

0 1 2 3

1 2 3 SIZE

p q r

s t u

p q r

s t u

0 1 2

Proceed to Section 3A

3A. ANY PLEURAL ABNORMALITIES CONSISTENT WITH PNEUMOCONIOSIS 3B. PLEURAL PLAQUES (mark site, calcification, extent, and width)
Chest wall In profile Face on Diaphragm Other site(s) Site Calcification

YES

Complete Sections 3B, 3C

NO

Proceed to Section 4A

O O O O

R R R R

L L L L

O O O O

R R R R

L L L L

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) (3mm minimum width required) 3 to 5 mm = a 5 to 10 mm = b > 10 mm = c

O 1

R 2 3

O 1

L 2 3

O a

R b c

O a

l b c

3C. COSTOPHRENIC ANGLE OBLITERATION 3D. DIFFUSE PLEURAL THICKENING

(mark site, calcification, extent and width)

Proceed to Section 3D

NO

Proceed to Section 4A

Chest wall In profile Face on

Site

Calcification

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) (3mm minimum width required) 3 to 5 mm = a 5 to 10 mm = b > 10 mm = c

O O

R R

L L

O O

R R

L L

O 1

R 2 3

O 1

L 2 3

O a

R b c

O a

l b c

4A. ANY OTHER ABNORMALITIES? 4B. OTHER SYMBOLS (OBLIGATORY)

aa OD at ax bu ca cg cn co cp cv di ef em es fr

YES

Complete Sections 4B, 4C, 4D, 4E

NO

Proceed to Section 5

hi

ho

id

ih

kl

me pa

pb

pi

px

ra

rp

tb

If other diseases or significant abnormalites, findings must be recorded on reverse. (section 4C/4D) Date Personal Physician or Worker notified?
MONTH DAY YEAR

4E.

Should worker see personal physician because of findings in section 4? Proceed to Section 5

YES

NO

FILM READER'S INITIALS 5.

DATE OF READING
MONTH DAY YEAR

Enter your name

certified B reader

05

24

2004
Reset

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

Abnormalites of the Diaphragm

Eventration Hiatal hernia

Lung Parenchymal Abnormalities

Azygos lobe Density, lung Infiltrate

Airway Disorders
Bronchovascular markings, heavy or increased Hyperinflation

Nodule, nodular lesion

Miscellaneous Abnormalities
Foreign body Post-surgical changes/sternal wire Cyst

Bony Abnormalities
Bony chest cage abnormality Fracture, healed (non-rib) Fracture, not healed (non-rib) Scoliosis Vertebral column abnormality

Vascular Disorders
Aorta, anomaly of Vascular abnormality

4D. OTHER COMMENTS