0920-24IK Physician Certifcation Document

PHYSICIAN APPLICATION FOR CERTIFICATION

STATUS

Department of Health and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
NIOSH
Coal Workers’ Health Surveillance Program (CWHSP)
1000 Frederick Lane, M/S LB208
Morgantown, WV 26508
FAX: 304-285-6058

Form Approved
OMB No.: 0920-0020

FOR NIOSH USE ONLY

ACTIVE STATE LICENSE(S)
State: ______ License #: __________________
State: ______ License #: __________________
State: ______ License #: __________________

NIOSH READER ID
NAME (LAST-FIRST-MIDDLE)

INITIALS

DATE OF BIRTH

HOSPITAL OR DEPARTMENT
STREET ADDRESS
CITY

STATE

COUNTRY

TELEPHONE NUMBER

ZIP CODE

EMAIL ADDRESS
During the last year, average number of chest radiographs viewed and assessed per month: ______
During the last year, average number of chest radiographs classified according to ILO system per month: ______
SPECIALITY:

Primary: ________________________

Board Certified?

Secondary: ______________________

Primary

Yes

No

Secondary:

Yes

No

I am applying to be an A Reader, and
I am submitting six chest radiographs, along with my classifications performed according the Guidelines
for the use of the ILO International Classification of Radiographs of Pneumoconioses; or
I have taken instruction in the current edition of the ILO International Classification of Radiographs of
Pneumoconioses
I attended the approved course at: ______________________ on _________________
City
Date
I am applying to be a B Reader.
Do not show any contact information on the internet (name and state only).
Use the same contact Information as provided above for the internet.
Use the following contact information on the internet.
HOSPITAL OR DEPARTMENT
STREET ADDRESS
CITY

STATE

COUNTRY

TELEPHONE NUMBER

EMAIL ADDRESS
CDC 2.12 (E), Rev. 03/2021

ZIP CODE

Are you employed by a Federal Government Agency?

Yes

No

If so, which one and where is your duty station? _____________________________________________________
Would you be interested in classifying chest radiographic images for NIOSH programs (e.g. CWHSP) Yes
Do you hold an active academic teaching appointment at a U.S. medical school? Yes

No

No

If yes, where? _______________________________________________________________________________
Do you anticipate that you will use this certification to document your credentials to classify chest radiographs for
other (non-NIOSH) programs or purposes?
Government Programs
Medical-Legal Activities
Yes
No
Yes
No
Individual Patient Care
Occupational Health Programs
Yes
No
Yes
No
Investigations / Research Yes
Other (describe below)
No
Yes
No
Describe “other” activity: ____________________________________________________________________
I agree that I will abide by the B Reader Code of Ethics when classifying chest radiographic images. If I participate in
the Coal Workers’ Health Surveillance Program, my performance will be conducted in the manner specified by HHS
regulation 42 C.F.R. Part 37, and I understand that information related to classifications of individual radiographs
made in connection with this program will be treated in a secure manner and will not be disclosed, unless otherwise
compelled by law. I further understand that: 1) My B Reader certification requires an active license to practice
medicine in the United States and I must notify the NIOSH B Reader Program within 60 days if my medical license is
revoked, suspended, voluntarily relinquished or surrendered, or converted to inactive status*; 2) NIOSH does not
regulate or monitor my classification of chest images performed for non-NIOSH purposes; 3) If NIOSH becomes
aware of violations, or allegations of violations, of the B Reader Code of Ethics, it may, at its discretion, notify
appropriate authorities, including the applicable State Board(s) of Medicine.
*Send written notification to:
NIOSH Coal Workers’ Health Surveillance Program, 1000 Frederick Lane, M/S LB208, Morgantown, WV 26508
DATE
FOR NIOSH USE ONLY
CERT DATE

PHYSICIAN SIGNATURE

TYPE OF EXAM
SCORE
B
R
STUDY METHOD
EXAM SITE
EXAM FORMAT
A
B
C
D
A
D
Public reporting burden of this collection of information is estimated to average 10 minutes per response, including
the 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 of information, including suggestions
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.

CDC 2.12 (E), Rev. 03/2021

DATE OF EXAM