Division of Coal Mine Workers' Compensation (DCMWC)

The enclosed Form CM-988, "Medical History and Examination for Coal Mine Workers' Pneumoconiosis," is used by the U.S. Department of Labor to obtain the examining physician's findings with respect to the existence, severity, and cause 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. Please note that this is a new form, replacing the previous version of the CM-988. There have been a number of minor revisions. It is important that you provide a response 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 B.1. Coal Mine Employment – CME.

Because total disability is defined as the miner's inability to perform his or her usual coal mine job (usually the miner's most recent job of at least one-year's duration), the examining physician must understand the physical requirements of the miner's coal mine employment. You must record the job title and describe the specific physical requirements of the miner's last coal mine job held for at least one year on Block B.1.a. In addition, we will provide you with Form CM-911a, "Employment History," whenever possible. This form contains the miner's own account of his or her work history and is provided to assist you in making an informed medical evaluation. Only Blocks B.1.a. and B.1.d. need to be completed when we have provided you with the "Employment History" form. If we do not provide the "Employment History" form, and it is not available from the Black Lung District Office that authorized this examination, you must obtain a brief work history from the miner for entry in Blocks B.1. and B.2.

Block D.4. Physical Findings.

Please concentrate on reporting findings that may be relevant to the patient's respiratory/pulmonary ability to perform his or her last coal mine work. Note any general findings you believe are important, such as blood pressure, temperature, and pulse. Also note any specific findings about the miner's extremities, thorax and lungs, heart, ENT, musculoskeletal structure, and abdomen that are relevant to your evaluation.

Block D.6.a. Respiratory/Pulmonary Diagnosis(es).

If you find that the patient has pneumoconiosis or any other respiratory/pulmonary condition, 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, as specifically requested. Your narrative should provide a complete rationale as to why you are diagnosing pneumoconiosis, particularly if your diagnosis is not clearly supported by the test results from Block D.5.

Block D.7. Etiology of Respiratory/Pulmonary Diagnosis(es).

Please describe the causes of each respiratory/pulmonary diagnosis above. Causes could include occupational or environmental exposures, genetic predisposition, personal habits, infectious agents, unknown, etc.

Please support your conclusion by citing the information obtained in your exam including exposure history, social history (e.g. smoking), chest imaging, test results and physical examination findings. Please describe the contribution of the miner's occupational dust exposure to his or her respiratory/pulmonary condition.

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 also as any chronic respiratory/pulmonary disease or impairment significantly related to, or substantially aggravated by, dust exposure in coal mine employment. This definition includes such diseases as chronic obstructive pulmonary disease (COPD), emphysema, and chronic bronchitis when they arise out of coal mine employment.

Block D.8. Disability/Impairment and Cause.

  1. Please describe the severity of any respiratory/pulmonary impairment that you diagnose. This impairment must then be compared to the exertional requirements of the miner's last coal mine job. You must reach one of two conclusions: (1) The patient is totally disabled for this last coal mine job due to the respiratory/pulmonary condition, or (2) he or she is not totally disabled and has the respiratory/pulmonary capacity to perform all the physical requirements of his or her last coal mine job. If you use the AMA Guides to Impairment DO NOT simply cite the impairment class alone, but also provide your reasoned opinion regarding the patient's ability to perform the duties required in his or her last coal mine job.
  2. Please explain your disability assessment with reference to the results of your examination and testing. In addition, if the miner's objective test results do not "qualify" to demonstrate total disability under the Department's pulmonary function or blood gas study guidelines, but you nevertheless diagnose total respiratory/pulmonary disability, please explain.
  3. If you diagnose a respiratory/pulmonary disability, identify the cause(s) of the disability, including pulmonary or non-pulmonary causes. Please report the extent to which each of the diagnoses you listed in D.6. contributes to the miner's disability. You may use percentages, proportions, or narrative, but please be thorough and ensure that you have weighed the contribution of each diagnosis to the disability. Include citations for any other sources you used in reaching your conclusions.

Block D.9. Non-pulmonary diagnosis.

Please report any cardiac or other diagnosis that may affect the miner's exertional ability from a respiratory standpoint. Be sure to state the degree of impairment, if any, and explain if the symptoms are similar to those of a respiratory/pulmonary diagnosis.

This form should be completed thoroughly to avoid the necessity of follow-up questions.

Please note that the examination report form CM-988 is available in electronic, fillable PDF format from the DCMWC website. You may file the completed form through DCMWC's C.O.A.L. Mine web portal or by mailing it to:U.S. Department of Labor OWCP/DCMWC, P.O. Box 8307, London, KY 40742-8307.

Revised August 2017