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The enclosed Form CM-988, “Medical History and Examination for Coal Mine Worker’s Pneumoconiosis,” is used by the U.S. Department of Labor to obtain the examining physician’s findings with respect to the existence, severity, and causality 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 as well. It is important that a response be provided 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 D. 6. Cardiopulmonary Diagnosis.
If you find that a patient has pneumoconiosis, 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. Your narrative should provide a complete rationale as to why you are diagnosing pneumoconiosis.
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 as any chronic pulmonary disease or respiratory disease or pulmonary impairment significantly related to, or substantially aggravated by, dust exposure in coal mine employment. This definition might include such diseases as chronic obstructive pulmonary disease (COPD), emphysema, and chronic bronchitis.
Block D. 7. Etiology of Cardiopulmonary Diagnosis.
Please describe the causes of each cardiopulmonary disease diagnosed above. The causes could be occupational or environmental exposures, genetic predisposition, related to personal habits, or unknown.
Please support your conclusion by citing the information obtained in your exam including exposure history, social history (e.g. smoking), and results of chest imaging and physiologic data. (Please feel free to attach additional sheets if necessary.)
Block D. 8. Impairment
(Note: The examining physician must be in a position to understand the physical requirements of the miner’s employment in the nation’s coal mines.)
- Please describe the severity of any cardiopulmonary impairment that you diagnose. This impairment must then be related to the exertional requirements of the miner’s last coal mine related work. You must reach one of two conclusions: 1) The patient is totally disabled for this last coal mine employment due to the cardiopulmonary condition, or 2) he or she is not totally disabled and has the pulmonary capacity to perform all the physical requirements of his or her last coal mine related work.
Please support your conclusion by citing the results of objective testing. This is especially important in cases where a miner otherwise fails to qualify as “totally disabled” under the Department’s pulmonary function or blood gas study guidelines. A rationale is needed in supporting a finding that the miner cannot now perform his/her current or last coal mining job.
If you diagnose a cardiopulmonary disease, from what genetic, social or work related source did this condition arise? Please provide a narrative with a rationale that supports your conclusion. You must take into account the x-ray, objective test data, social history (e.g., smoking, etc.) all known work history (e.g., dust exposure, etc.) in reaching your conclusion. Also, cite any other sources you used to support your conclusions, such as the AMA Guides to the Evaluation of Impairment. (Please feel free to attach additional sheets if necessary.)
This form should be completed thoroughly to avoid the necessity of follow-up questions.
Please note the attachment of Form CM-911a, “Employment History,” to the CM-988. This form contains the miner’s own account of his work history and is provided to assist the examining physician in making an informed medical evaluation. Only Block D.1.a. needs to be completed when the “Employment History” form is attached. If the “Employment History” is not attached, and is not available from the Black Lung District Office that authorized this examination, the physician is required to obtain a brief work history from the miner for entry in Blocks B.1. and B.2.
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