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  • May 15, 2026

How to Fill Out DOL Form CM-933 (w/Examples) + FAQs

Form CM-933 is the U.S. Department of Labor’s “Report of Pulmonary Evaluation” used to document a coal miner’s medical exam in a federal Black Lung benefits claim, and you fill it out by having a qualified physician complete every clinical section after a complete pulmonary evaluation, then attaching the chest X-ray reading, pulmonary function test, and arterial blood gas results before the doctor signs and dates the certification. The form is the centerpiece of the medical evidence the Division of Coal Mine Workers’ Compensation reviews under the Black Lung Benefits Act.

The governing rules sit in 20 C.F.R. Part 718, which sets the medical standards a doctor must meet for the report to count as evidence. If the report misses a required element, the district director can reject the exam, and your claim can be denied even when real disease exists under 20 C.F.R. §725.406.

About one in five long-tenured underground coal miners shows radiographic evidence of coal workers’ pneumoconiosis on screening, according to NIOSH Coal Workers’ Health Surveillance data, which is why CM-933 is filed in thousands of claims each year.

Here is what you will learn in this guide:

  • 📋 How to complete every line of CM-933 with claimant-ready language and physician-ready clinical detail.
  • 🩺 How 20 C.F.R. Part 718 quality standards apply to X-rays, pulmonary function tests, and blood gas studies.
  • ⚖️ How the “15-year presumption” under §411(c)(4) can shift the burden to the coal mine operator.
  • 🧾 How to use your right to a complete pulmonary evaluation paid by the Department of Labor.
  • 🚫 How to avoid the seven mistakes that sink most CM-933 reports before a judge ever sees them.

What Form CM-933 Is and Why It Exists

Form CM-933 is the standardized “Report of Pulmonary Evaluation” the Office of Workers’ Compensation Programs sends to a physician chosen by the claimant after a Black Lung claim is filed. The form gives the doctor a single document to record the miner’s history, exam, test results, and final diagnosis so the district director can decide whether the miner has pneumoconiosis and is totally disabled by it. Without CM-933, every doctor would write a different narrative, and the district director could not compare evidence across claims fairly.

The legal authority for the form comes from the Black Lung Benefits Act and its rules at 20 C.F.R. Part 718. Part 718 lists the medical criteria for proving the disease, the level of breathing impairment, and the cause, and CM-933 is built to track those criteria line by line. The consequence of skipping a line is real, because under 20 C.F.R. §718.104 a report that lacks a reasoned medical opinion is given little or no weight by an Administrative Law Judge.

Picture Earl, a 62-year-old retired underground miner from Pike County, Kentucky, with 28 years on the face. He files a claim, and the DOL mails him a packet that includes Form CM-933 along with a list of approved physicians within driving distance. Earl picks a board-certified pulmonologist who is also a NIOSH B-reader, and the entire exam, X-ray, spirometry, blood gas, and CM-933 paperwork is paid by the Black Lung Disability Trust Fund.

A common misconception is that any chest X-ray or family doctor’s note can substitute for CM-933. It cannot, because the evidence-limitation rule at 20 C.F.R. §725.414 caps how many medical reports each side can submit, and an unstructured note rarely meets the Part 718 quality standards.

Who Files CM-933 and When

CM-933 is filled out by the examining physician, not the miner, but the miner triggers the form by filing a benefits claim on Form CM-911 or, for survivors, on Form CM-912. Once the district director receives the claim, the agency schedules the complete pulmonary evaluation within a few weeks, and the doctor returns the completed CM-933 directly to the DOL. Survivors filing on behalf of a deceased miner usually rely on autopsy or hospital records, but if the miner died before a CPE could be done, CM-933 is not used and the claim turns on autopsy reports under 20 C.F.R. §718.106.

The timing matters because under 20 C.F.R. §725.405 the district director must develop the medical evidence quickly, and a delay in scheduling the exam can push back the proposed decision and order. The consequence of waiting too long to choose a doctor is that the DOL may pick one for you, and that physician may not be the most experienced in pneumoconiosis cases. A practical example is Brenda, a surviving spouse in Logan County, West Virginia, who waited four months to schedule her late husband’s records review; the district director issued a schedule for submission of additional evidence anyway, narrowing her window to develop the claim.

A common misconception is that the miner’s personal physician can simply mail in CM-933 unsolicited. The form must be tied to a DOL-authorized exam, and submitting an unauthorized CM-933 outside the §725.406 process risks having the report excluded as exceeding the evidentiary limits.

Section-by-Section Walkthrough of CM-933

Section 1: Identifying Information

The top of CM-933 captures the miner’s full legal name, Social Security Number, date of birth, and the OWCP claim number assigned when the claim was filed. The physician’s name, address, NPI, and specialty go on the right side. The consequence of an SSN typo is that the report can be matched to the wrong claim file and lost in the agency’s Energy Employees and Black Lung database, which can take weeks to fix.

A real example is Marcus, a 58-year-old surface mine equipment operator in Boone County, West Virginia. His claim number begins with the letter prefix used by the Charleston district office, and his physician copies it from the DOL cover letter onto CM-933 to make sure every page of evidence stays linked to the right file.

A common misconception is that a wrong claim number can be fixed later by the lawyer. It can, but the delay can cost the miner months of retroactive benefits, because under 20 C.F.R. §725.503 entitlement begins the month the claim is filed only if the file is processed without administrative dead-ends.

Section 2: Coal Mine Employment History

This section asks for every coal mine job, the dates worked, the job title, and whether the work was underground, surface, or both. The physician relies on the miner’s own report here, but the legally binding employment history is the one the DOL develops from Social Security earnings records under 20 C.F.R. §725.101(a)(32). The years matter because crossing the 15-year threshold triggers the rebuttable presumption in 20 C.F.R. §718.305 that a totally disabling respiratory impairment is due to pneumoconiosis.

The consequence of underreporting years is huge. If the miner says “about 12 years” when the real number is 17, the doctor may not flag the 15-year presumption, and the operator’s lawyer may argue the presumption never applied. Earl from the earlier example lists each mine he worked at with month-and-year start and stop dates, even where he held multiple jobs at the same operator, to lock in his 28-year tenure.

A common misconception is that surface-mine years do not count toward the 15. They do, as long as the work involved exposure to coal mine dust comparable to underground conditions, a question explored in cases like Director, OWCP v. Midland Coal Co. and clarified in the Department’s 2013 amendments to Part 718.

Section 3: Smoking and Personal Medical History

CM-933 asks for pack-year smoking history, other lung diseases, cardiac history, and any non-mining dust exposures. The doctor needs this to give a reasoned opinion on causation under 20 C.F.R. §718.201(a)(2), which defines “legal pneumoconiosis” as any chronic lung disease arising out of coal mine employment. The consequence of leaving smoking blank is that the operator will argue the impairment is purely tobacco-related, and the judge may agree without a clear medical explanation tying dust exposure to the disease.

A real example is Linda, a 60-year-old former tipple operator in Mingo County who smoked for 20 years and quit in 2010. Her physician records “20 pack-years, quit 16 years ago” and then explains in Section 6 that her chronic bronchitis is substantially aggravated by coal dust based on the pattern of fixed obstruction on spirometry. That sentence-level reasoning is what wins claims under Cornett v. Benham Coal and similar precedent.

A common misconception is that any history of smoking defeats a black lung claim. It does not, because legal pneumoconiosis can coexist with smoking-related disease, and the law only requires coal dust exposure to be a substantially contributing cause.

Section 4: Symptoms and Physical Examination

This section captures dyspnea on exertion, cough, sputum, wheeze, chest pain, height, weight, blood pressure, and a full chest exam. The doctor grades dyspnea using a standard scale and notes any clubbing, cyanosis, or wheezes. The consequence of a vague exam (“lungs clear”) with abnormal tests is that the report looks internally inconsistent, and an ALJ can discount it under Director v. Greenwich Collieries.

For example, a physician examining Earl writes “decreased breath sounds at both bases, no wheeze, no clubbing, MRC dyspnea grade 4 (stops for breath after 100 yards).” This level of detail lines up with the spirometry findings and gives the report internal consistency.

A common misconception is that physical exam findings alone can prove total disability. They cannot, because 20 C.F.R. §718.204(b) requires objective testing or, if testing cannot be done, a reasoned physician opinion supported by medically acceptable clinical findings.

Section 5: Diagnostic Test Results

CM-933 has dedicated subparts for chest X-ray, pulmonary function (spirometry), arterial blood gas, EKG, and any other studies. Each test must meet the quality standards in 20 C.F.R. Part 718, Subpart C and Appendices A through C. Missing a quality standard does not always invalidate the test, but it gives the other side a strong attack.

Chest X-ray and ILO Classification

The X-ray must be classified using the ILO 2011 (or later) classification system by a NIOSH-certified B-reader. Profusion is recorded as 0/0, 0/1, 1/0, 1/1, 1/2, and so on, and any large opacity (A, B, or C) signals complicated pneumoconiosis. The consequence of an unclassified film is that it carries little weight, while a film read as 1/0 or higher by a B-reader meets the radiographic criterion in 20 C.F.R. §718.202(a)(1).

For example, Marcus gets a digital chest X-ray that a B-reader classifies as 1/1 q/q with small rounded opacities in the upper zones. That single number, written into Section 5, is enough to establish clinical pneumoconiosis without anything else.

Pulmonary Function Test (Spirometry)

The PFT records FEV1, FVC, and the FEV1/FVC ratio, both before and after a bronchodilator. To be “qualifying” for total disability under Appendix B to Part 718, the values must fall below tables tied to the miner’s height and age. The consequence of a non-qualifying PFT is that the miner must prove disability by other means, usually a blood gas study or a reasoned medical opinion under §718.204(b)(2)(iv).

Arterial Blood Gas Study

The ABG measures PaO2 and PaCO2 at rest and, if safe, after exercise. Qualifying values are listed in Appendix C to Part 718. A qualifying ABG independently proves total disability even if the PFT is normal, which often happens with miners who have gas-exchange impairment from interstitial fibrosis rather than airway obstruction.

EKG and Other Studies

An EKG can show cor pulmonale or right-heart strain, which supports a finding of disabling impairment when paired with a qualifying ABG. The doctor may also order a CT scan, though CT findings are not listed in the regulatory criteria and are usually treated as supportive rather than independent proof.

Section 6: Diagnosis and Medical Reasoning

This is the most important section. The physician must answer three questions:

  • Does the miner have pneumoconiosis as defined at 20 C.F.R. §718.201?
  • Did the pneumoconiosis arise out of coal mine employment under §718.203?
  • Is the miner totally disabled by a respiratory or pulmonary impairment under §718.204?

The consequence of a one-word “yes” or “no” is that the report fails the reasoned opinion requirement and gets little weight. The doctor needs to explain why, citing the X-ray reading, the PFT, the ABG, the smoking history, and the dust exposure. Courts including the Sixth Circuit in Crockett Collieries v. Barrett have repeatedly held that conclusory opinions cannot carry the burden of proof.

A common misconception is that the doctor must say the magic words “total disability.” The doctor must instead describe an impairment that prevents the miner from doing his usual coal mine work, which under Mancia v. Director, OWCP means the last regular coal mine job or one of comparable exertion.

Section 7: Physician Certification and Signature

The doctor signs, dates, lists credentials, and certifies that the report is true and complete. Missing the signature voids the report. The credentials matter because a board-certified pulmonologist’s opinion typically carries more weight than a general practitioner’s, a point reinforced in Underwood v. Elkay Mining Co. and similar precedent.

Three Common CM-933 Scenarios

Claim Pattern Likely DOL Outcome
30-year underground miner, B-reader X-ray 2/1, qualifying PFT, non-smoker Award; clinical pneumoconiosis plus total disability invokes §411(c)(4) presumption and operator rarely rebuts
18-year surface miner, X-ray 0/1, non-qualifying PFT, qualifying resting ABG, 25 pack-year smoker Award likely if doctor explains dust as substantial contributor to gas-exchange impairment under legal pneumoconiosis definition
10-year miner, negative X-ray, normal PFT, normal ABG, heavy smoker Denial; no clinical or legal pneumoconiosis and no total disability under §718.204

Three Named Examples Walking Through CM-933

Earl, the 28-Year Underground Miner

Earl files Form CM-911 at the Mt. Sterling, Kentucky district office. The DOL schedules him with a board-certified pulmonologist who is also a B-reader. The X-ray reads 1/1, FEV1 is 48% of predicted, and resting PaO2 is 58 mmHg. The doctor checks “yes” to clinical pneumoconiosis, “yes” to coal mine employment causation, and “yes” to total disability, then writes a paragraph tying each finding to the coal dust exposure history. Because Earl has more than 15 years of qualifying employment and a totally disabling respiratory impairment, the §411(c)(4) presumption shifts the burden to the operator, and the district director issues a Proposed Decision and Order awarding benefits.

Linda, the Tipple Operator with Mixed Disease

Linda worked 22 years at a tipple, smoked 20 pack-years, and now has FEV1 of 58% of predicted and a normal ABG. Her X-ray is 0/1, just below the clinical threshold. Her physician finds legal pneumoconiosis by explaining that her chronic bronchitis arose at least in part from coal dust under §718.201(a)(2). Because her PFT is not qualifying, the doctor relies on the §718.204(b)(2)(iv) “reasoned medical opinion” route, citing her exertional dyspnea and the heavy lifting her tipple job required.

Brenda, the Surviving Spouse

Brenda is the widow of a 35-year underground miner who died of respiratory failure. CM-933 itself does not apply to her, but she submits autopsy slides under 20 C.F.R. §718.106. The autopsy shows complicated pneumoconiosis (a Category A large opacity), which under §718.304 is an irrebuttable presumption of total disability due to pneumoconiosis and entitles her to survivor’s benefits.

Mistakes to Avoid

  • Leaving the OWCP claim number blank, which can detach the report from the file under the DCMWC procedural rules.
  • Underreporting coal mine years, which can cost you the 15-year presumption.
  • Using an X-ray reader who is not a NIOSH-certified B-reader, which weakens the radiographic evidence.
  • Submitting a PFT without three acceptable, reproducible efforts under Appendix B tracings, which makes the test invalid.
  • Writing a one-line diagnosis with no reasoning, which fails the reasoned opinion rule in §718.104.
  • Forgetting to address smoking as a competing cause, which lets the operator argue tobacco is the only cause.
  • Skipping the physician’s signature or date, which voids the report under DOL practice.
  • Sending the form to the wrong district office, delaying processing for weeks.
  • Mixing up “clinical” and “legal” pneumoconiosis categories under §718.201, which confuses the record.
  • Failing to note bronchodilator response on spirometry, which can make a fixed obstruction look reversible.

Do’s and Don’ts of CM-933

Do’s

  • Do choose a DOL-authorized physician so the exam qualifies as the complete pulmonary evaluation.
  • Do request a B-reader interpretation of every chest film to maximize evidentiary weight.
  • Do attach raw spirometry tracings and ABG lab reports because Part 718 quality standards require source data.
  • Do ask the doctor to explicitly compare the impairment to your usual coal mine work under §718.204(b)(1).
  • Do keep a personal copy of every CM-933 page so you can respond if the operator sends a contrary Form CM-913 report.

Don’ts

  • Don’t sign blank pages of CM-933 because the certification is the doctor’s, not yours.
  • Don’t let the operator pick your physician for the CPE; the right of choice belongs to the miner.
  • Don’t submit duplicate medical reports beyond the §725.414 evidentiary limits.
  • Don’t accept a one-page narrative in place of the structured CM-933 form.
  • Don’t ignore the 60-day window to respond to the schedule for submission of additional evidence.

Pros and Cons of the CM-933 Process

Pros

Cons

  • Operators almost always counter with their own Part 725 evidence, creating a “battle of experts.”
  • Quality-standard rejections can sink an otherwise strong report under §718.103.
  • Wait times for B-reader and pulmonologist appointments can stretch the claim by months.
  • The form’s clinical detail is intimidating for non-physician readers without DCMWC procedure manual guidance.
  • Travel to an approved facility is sometimes a hardship in remote Appalachian counties.

Federal Versus State Pneumoconiosis Programs

The federal Black Lung program created by the Black Lung Benefits Act runs in parallel with state workers’ compensation systems in Kentucky, West Virginia, Virginia, and Pennsylvania. The federal program uses CM-933; the state programs use their own forms with their own thresholds. The consequence of confusing the two is that a miner may file in only one system when he is eligible for both, leaving money on the table.

For example, a Pennsylvania miner with Category 1 simple pneumoconiosis can sometimes recover a state occupational disease award under the Pennsylvania Workers’ Compensation Act and federal benefits at the same time, with §725.535 offset rules coordinating the two. A common misconception is that a state denial bars a federal claim. It does not, because the federal program applies its own criteria under Part 718.

Key Court Rulings That Shape CM-933

The Supreme Court upheld the constitutionality of the Black Lung Benefits Act in Usery v. Turner Elkhorn Mining Co., confirming that operators can be liable for occupational lung disease. The Court later clarified the burden of proof in Mullins Coal Co. v. Director, OWCP, and the burden-shifting framework in Director v. Greenwich Collieries. The Fourth Circuit’s decision in Eastern Associated Coal Corp. v. Director, OWCP shaped how operators must rebut the §411(c)(4) presumption.

The consequence of these rulings is a body of case law that rewards CM-933 reports written with detailed, reasoned opinions and punishes vague ones. A common misconception is that case law is too technical to matter to the doctor filling out the form. It matters greatly, because the language the doctor uses inside Section 6 either tracks the case law or invites attack.

Key Entities to Know

FAQs

Is Form CM-933 the same as Form CM-911?

No. CM-911 is the miner’s claim application; CM-933 is the physician’s pulmonary evaluation report completed after a DOL-scheduled exam.

Do I have to pay for the CM-933 exam?

No. The complete pulmonary evaluation under §725.406 is paid by the Black Lung Disability Trust Fund, so the miner owes nothing for the exam, X-ray, or testing.

Can my family doctor fill out CM-933?

No. Only a physician authorized by the DOL through the §725.406 process may complete the form, though you may pick that physician from an approved list near your home.

Does a positive X-ray alone win my claim?

No. A positive ILO-classified X-ray proves clinical pneumoconiosis but you still must show total disability under §718.204 unless the disease is complicated.

Can I add my own private medical reports?

Yes. You may submit additional evidence inside the §725.414 evidentiary limits, generally two affirmative medical opinions and supporting tests per side.

Does smoking automatically defeat my claim?

No. Coal dust only needs to be a substantially contributing cause of impairment under §718.201(a)(2), so claims with mixed smoking and dust exposure can still succeed.

Do surface-mine years count toward the 15-year presumption?

Yes. Surface work counts when dust conditions are substantially similar to underground work, as recognized in the Byrd Amendments rulemaking.

Can survivors use CM-933?

No. Survivors typically rely on hospital records and autopsy reports under §718.106 because CM-933 is built around a living-miner exam.

Will the operator see my CM-933?

Yes. Once the district director issues the Proposed Decision and Order, the responsible operator gets the full medical record and can submit competing evidence.

Can I appeal if my CM-933 is rejected?

Yes. You may request a hearing before the Office of Administrative Law Judges and then appeal to the Benefits Review Board and the federal courts of appeals.

Does state black lung law affect the federal CM-933?

No. Federal CM-933 evidence is judged only against 20 C.F.R. Part 718 standards, though state awards may offset benefits under §725.535.

Is there a deadline to submit CM-933 evidence?

Yes. The district director sets a schedule for submission of additional evidence, typically 60 days, and missing it can lock you out of adding new reports.

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