This is the core report of the DOL-sponsored complete pulmonary evaluation for a coal miner's black lung claim, which usually also includes a chest x-ray, ventilatory study and arterial blood gas test. The examining physician records work, family, medical and smoking history, symptoms and physical findings, then gives a reasoned opinion on respiratory diagnoses, their causes, and whether the miner is totally disabled for the last coal mine job.
The examining physician completes every section from A to F, types their name on the front page and signs section F. The miner helps with the employment history; when DOL supplies Form CM-911a, only blocks B.1.a and B.1.d are needed there.
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Medical History and Examination for Coal Mine Workers' Pneumoconiosis
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Total disability is the miner's inability to perform their usual coal mine job, usually the most recent job held for at least one year, because of a respiratory or pulmonary condition. That is why block B.1.a asks for the job title, physical requirements and exertion level, and D.8 compares the impairment to that job.
If DOL provides Form CM-911a, the miner's own work history, review it with the miner and complete only blocks B.1.a (last coal mine job of at least one year) and B.1.d (protective equipment). If no CM-911a is available, take a brief work history from the miner and complete blocks B.1 and B.2.
Only DOL-approved diagnostic providers perform the DOL-sponsored exam, and DCMWC publishes an approved provider list. The fillable form is on DCMWC's website, and the guide on its last pages explains what DOL expects in the employment, findings, diagnosis, etiology and disability blocks.