Attachment 1 - NAVMED 62607 Form.pdf

NAVY OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

ROENTGENOGRAPHIC INTERPRETATION FOR PNEUMOCONIOSES

WORKER DOD ID NUMBER

CONTROL NUMBER (NMCPHC Use Only)

SE

C

TI

O N

SE

C

TI

O N

SE

C

TI

O N

SE

C

TI

O N

Asbestos ☐ Silica ☐ Sections 133, 101-87-3012, 5031 and 8012, Title 10 USC & Exec. Order 9897 (Privacy Act of 1974) Apply

WORKER SSN

NAME (LAST or SURNAME) (FIRST) (MI)

DATE OF BIRTH

Year Month Day

DATE OF X-RAY

Year Month Day

OCCUPATIONAL CODE

(Civilian Only)

ENLISTED

Ratings/MOS NEC

OFFICERS

NOBC DESIGNATOR

HULL LETTERS NUMBERS

PAY GRADE _ _

YRS GOV’T SRVC

GENDER

☐M ☐F

ETHNICITY (RACE)

☐ White ☐ Black ☐ Hispanic ☐ Asian ☐ Native American ☐ Other

STATUS (CHECK ONE)

☐ Navy ☐ Marines ☐ Coast Guard ☐ Army ☐ Air Force ☐ Civilian

Military Only:

Shipboard Only:

EXAM PURPOSE

☐Initial ☐Periodic ☐Termination ☐Situational

EXAM FACILITY UIC

Original: Worker’s Health Record Copy: Navy and Marine Corps Public Health Center 620 John Paul Jones Cir Ste 1100, Portsmouth, VA 23708-2111

EXAMINATION FACILITY NAME

X-RAY NEGATIVE FOR PNEUMOCONIOSIS

Mark one box and proceed to Section 5

X-RAY SHOWS ABNORMALITIES CONSISTENT WITH

PNEUMOCONIOSIS Mark box and proceed to Section 3

FILM QUALITY If NOT Grade 1, give main reason 0/-1 0/13 0/02 U

ANY PARENCHYMAL ABNORMALITIES

CONSISTENT WITH PNEUMOCONIOSIS?

If YES, complete 3B & 3C If NO, proceed to SECTION 4

SMALL OPACITIES a. SHAPE/SIZE c. PROFUSION

SIZE

LARGE OPACITIES

Primary Secondary

b. ZONES

YES NO3A

3B 3C

Proceed to Section 4

1/0 2/1 3/2

1/2 2/3 3/+ pp B0ss CA qq tt rr uu

1/1 2/2 3/3

If YES, complete 4B,C,D,E If NO, proceed to SECTION 5

PLEURAL THICKENING - CHEST WALL

PLEURAL PLAQUE (DIAPHRAGM) PLEURAL PLAQUE (PERICARDIUM) COSTOPHRENIC ANGLE

OBLITERATION

a. CIRCUMSCRIBED (PLAQUE)

NONE

WIDTH

EXTENT

EXTENT

CALCIFICATION

YES NO

4A

4B

4C 4D 4E

B

C

A

R

ANY PLEURAL ABNORMALITIES CONSISTENT

WITH PNEUMOCONIOSIS?

SE

C

TI

O

N

FA

CE

O

N P

RO

FI

LE

b. DIFFUSE

NONE

a. Plaque

WIDTH WIDTH

EXTENT EXTENT

EXTENT EXTENT

CALCIFICATION CALCIFICATION

B B

2 2

2 2

2 2

0 0

0R

0 0

0 0

0 0

C C

3 3

3 3

3 3

A A

L

LBoth

1 1

1 1

1 1

WIDTH

EXTENT

EXTENT

CALCIFICATION

b. Calcification

B

C

A

RL

RI

GH

T

LE

FT

R

Year Month Day

DATE OF READING _ _ _ _ _ _ _ _NAVY B-READER NUMBER _ _ _

OTHER ABNORMALITIES? (OBLIGATORY)

0 aa at ax bu ca cg cn co cp cv di ef em es fp fr hi ho id ih kl me pa pb pi px rp tb

PRESENT PRESENT NONE 0 NONE 0RI

GH

T

LE

FTPRESENT R PRESENT L

20 31L

a. Plaque b. Calcification

20 31R 20 31L

Overexposed Underexposed Poor resolution Artifacts, damaged cassette, grid, or screen Improper position or patient motion

Film fogged Poor inspiration Other

Both0 R BothL0

NAVMED 6260/7 (REV SEP 2016)

NMCPHC TM OM 6260, NMCPHC TM OEM 6260.96-2

(for example, GS-1234)

WORKER

☐ Current ☐ Past

X-RAY ACCESSION NUMBER (IMAGE ID)

R L

Upper Middle Lower

CALCIFICATION CALCIFICATION CALCIFICATION2 20 03 31 1CALCIFICATION 20 3120 1 3

Other____________ ra

0 None aa atherosclerotic aorta at significant apical pleural thickening ax coalescence of small pneumoconiotic opacities bu bulla(e) ca cancer of the lung or pleura cg calcified non-pneumoconiotic nodules (e.g. granuloma) or nodes cn calcification in small pneumoconiotic opacities co abnormal cardiac size or shape cp cor pulmonale cv cavity di marked distortion of the intrathoracic organs ef effusion em definite emphysema es eggshell calcification of hilar or mediastinal lymph nodes fp subpleural fat fr fractured rib(s) hi enlargement of hilar or mediastinal lymph nodes ho honeycomb lung id ill defined diaphragm ih ill defined heart outline kl septal (Kerley) lines me mesothelioma pa plate atelectasis pb parenchymal bands - significant parenchymal fibrotic stands in continuity with the pleura pi pleural thickening in the interlobar fissure or mediastinum px pneumothorax ra rounded atelectasis rp rheumatoid pneumoconiosis tb tuberculosis

SECTION 5 Other Abnormalities: Code Descriptions