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

Form CM-933b is the U.S. Department of Labor’s “Report of Physical Examination for Coal Mine Workers’ Pneumoconiosis,” and you fill it out by recording a miner’s work history, symptoms, physical findings, chest X-ray results, pulmonary function values, arterial blood gas studies, and a final medical opinion on whether the miner has pneumoconiosis caused by coal-mine dust exposure. The form is a core piece of medical evidence in every federal Black Lung benefits claim, and the Division of Coal Mine Workers’ Compensation (DCMWC) uses it to decide whether a miner qualifies for monthly benefits and medical treatment under the Black Lung Benefits Act.

The problem the form addresses is proof. A miner cannot win a federal Black Lung claim by simply saying he is sick, because the regulations at 20 C.F.R. Part 718 require objective medical evidence of pneumoconiosis, total disability, and a causal link to coal-mine employment. If the CM-933b is incomplete, illegible, or fails to meet the quality standards in 20 C.F.R. § 718.104, the claims examiner can give it little or no weight, and the miner can lose benefits worth thousands of dollars a year.

According to the DOL’s FY 2023 Black Lung Annual Report, more than 23,000 miners and survivors received federal Black Lung benefits, with monthly payments ranging from roughly $773 for a single beneficiary to over $1,547 for a miner with three or more dependents. A single defective CM-933b can be the difference between approval and denial.

Here is what you will learn in this guide:

📋 How to complete every line of CM-933b without triggering a rejection from DCMWC.
🩺 How the form interacts with X-ray readings (Form CM-933), pulmonary function studies, and arterial blood gas tests.
⚖️ Which federal regulations and court rulings control how the form is weighed as evidence.
🧾 Real named-miner examples showing correct and incorrect entries side by side.
🚫 The most common mistakes claimants, physicians, and representatives make, and how to avoid them.

What Form CM-933b Is and Why It Exists

Form CM-933b is the Report of Physical Examination that a physician completes after performing a complete pulmonary evaluation of a coal miner. The form lives inside a larger packet the DOL sends to every miner who files a claim, which also includes Form CM-911a (Claim for Benefits), Form CM-913 (Description of Coal Mine Work), and Form CM-988 (Employment History).

The plain-English purpose of CM-933b is to give the DOL one organized document that captures the physician’s findings, the objective test results, and the physician’s reasoned opinion. Under the quality standards in 20 C.F.R. § 718.101, every medical report must be “sufficiently detailed” and explain the reasoning behind any conclusion. A bare conclusion like “miner has black lung” carries almost no weight in front of an Administrative Law Judge.

The consequence of skipping or rushing this form is severe. If the physician’s report is not “documented and reasoned” under the standard set in Director, OWCP v. Rowe, 710 F.2d 251 (6th Cir. 1983), the ALJ can disregard it entirely. The miner then loses the only piece of evidence that ties his lung disease to coal-mine dust.

A common misconception is that any family doctor can fill out CM-933b. In reality, the DOL pays for a complete pulmonary evaluation by a physician of the miner’s choice under 30 U.S.C. § 923(b), and that physician should be board-certified in internal medicine or pulmonary disease whenever possible. A B-reader certification from NIOSH is required for the doctor reading the chest X-ray, though not always the same doctor who completes CM-933b.

A real-world example helps. Earl, a 32-year underground miner from Logan County, West Virginia, files a claim in 2026. The DOL schedules him for a complete pulmonary evaluation with Dr. Patel, a board-certified pulmonologist. Dr. Patel fills out CM-933b, attaches the X-ray reading on Form CM-933, the spirometry tracings, and the arterial blood gas results. Because each piece is tied together inside CM-933b, the district director can issue a Proposed Decision and Order in Earl’s favor within months instead of years.

The Legal Framework Behind CM-933b

The form does not exist in a vacuum. It carries the weight of an entire federal statute, two parts of the Code of Federal Regulations, and decades of Benefits Review Board and federal circuit case law.

The Black Lung Benefits Act

The Black Lung Benefits Act of 1969, as amended, creates the right to monthly benefits and medical care for coal miners totally disabled by pneumoconiosis. The Act is codified at 30 U.S.C. §§ 901–945. The plain-English explanation is that Congress decided coal miners who get sick from coal dust deserve federal compensation because state workers’ compensation systems were leaving them behind. The consequence of the Act is that miners and survivors can recover even decades after leaving the mines. A common misconception is that the law only covers underground miners, but Section 902(d) defines “miner” to include surface workers and coal preparation plant workers as well.

20 C.F.R. Part 718 Quality Standards

Part 718 sets the medical criteria for proving pneumoconiosis. The quality standards for physical examinations sit at 20 C.F.R. § 718.104, and they tell the physician exactly what to include. The consequence of skipping a required element, such as a smoking history or a list of all symptoms, is that the report may be rejected as non-conforming. A real example: in Patriots Coal Co. v. Director, OWCP, the Sixth Circuit affirmed an ALJ who discounted a physician’s report for failing to explain how the miner’s coal-mine dust exposure contributed to his impairment.

20 C.F.R. Part 725 Procedure

Part 725 governs the claims process itself. Section 725.406 entitles every miner to a complete pulmonary evaluation paid for by the DOL, and CM-933b is the vehicle for that evaluation. The consequence of not requesting this DOL-paid exam is that the miner must pay out of pocket for his own pulmonologist, which can cost $2,000 or more.

Step-by-Step: Filling Out CM-933b Line by Line

The form is divided into sections that mirror a standard pulmonary workup. Each section has line-item nuances that change the weight the ALJ gives the report.

Section 1: Miner Identification

This section captures the miner’s full legal name, Social Security number, address, date of birth, and DOL claim number. The plain-English purpose is to match the report to the correct claim file. The consequence of a wrong SSN or claim number is that the report may be filed in the wrong case, delaying the decision by weeks. A common mistake is using a nickname or married name that does not match the Social Security Administration record.

Maria, the widow of a Pennsylvania miner named Frank, lists herself on her CM-933b survivor packet using her remarried name. The DOL cannot match it to Frank’s claim, and her benefits are delayed four months until she submits a corrected form.

Section 2: Coal Mine Employment History

The physician records the miner’s years of coal-mine work, job titles, and dust exposure. This section ties directly to the 15-year rebuttable presumption in 30 U.S.C. § 921(c)(4), which presumes a totally disabled miner with 15 or more years of qualifying coal-mine employment and a totally disabling respiratory impairment has pneumoconiosis. The consequence of underreporting years is losing the presumption. A misconception is that only underground years count, but surface mine years qualify if the dust exposure was comparable, as confirmed in Antelope Coal Co./Rio Tinto Energy America v. Goodin, 743 F.3d 1331 (10th Cir. 2014).

Section 3: Smoking History

The physician must record packs per day, years smoked, and current smoking status. The plain-English purpose is to separate coal-dust disease from cigarette-related COPD. The consequence of an incomplete smoking history is that a defense pulmonologist can attack the report for failing to consider alternative causes. The misconception is that smoking disqualifies a miner from Black Lung benefits, but under 20 C.F.R. § 718.201(a)(2), “legal pneumoconiosis” includes any chronic lung disease “arising out of” coal-mine employment, even if smoking also contributed.

Section 4: Symptoms and Medical History

This section lists shortness of breath, cough, sputum, wheezing, chest pain, and any prior lung disease. The consequence of skipping symptoms is that the ALJ may find the physician did not perform a thorough exam. A real example: Jasper, a 28-year Kentucky miner, tells Dr. Lee he gets short of breath walking to the mailbox, but Dr. Lee only checks “dyspnea on exertion.” On cross-examination, the defense argues the report is too vague to support total disability. A better entry would say “dyspnea after walking 50 feet on level ground.”

Section 5: Physical Examination Findings

The physician records vital signs, height, weight, chest configuration, breath sounds, and any rales, rhonchi, or wheezes. Height matters because pulmonary function predicted values depend on it under the tables in Appendix B to 20 C.F.R. Part 718. The consequence of recording the wrong height is that the spirometry interpretation can flip from qualifying to non-qualifying. A misconception is that small height errors do not matter, but a two-inch difference can change a miner’s FEV1 percent predicted by 5 to 7 percent.

Section 6: Chest X-Ray Results

This section summarizes the chest X-ray reading, which is usually attached as Form CM-933 (Roentgenographic Interpretation). The reading must use the ILO classification system, and the reader should be a NIOSH-certified B-reader for maximum weight. The consequence of using a non-B-reader is that the reading carries less weight under 20 C.F.R. § 718.202(a)(1). A misconception is that a negative X-ray ends the claim, but pneumoconiosis can be proven by biopsy, autopsy, or a reasoned medical opinion under § 718.202(a)(4).

Section 7: Pulmonary Function Study

Spirometry values for FEV1, FVC, and MVV are entered here, along with the best of three tracings. The values are compared to the tables in Appendix B to Part 718 to see if the miner meets the disability thresholds. The consequence of poor effort or fewer than three tracings is that the test is non-conforming. A misconception is that a single qualifying value wins the case, but the ALJ weighs all the evidence together.

Section 8: Arterial Blood Gas Study

Resting and exercise PO2 and PCO2 values are recorded and compared to Appendix C to Part 718. The consequence of skipping the exercise study, when the resting values are non-qualifying, is that the miner loses a chance to prove disability. A misconception is that blood gas tests are optional, but 20 C.F.R. § 718.105 requires them as part of a complete evaluation unless medically contraindicated.

Section 9: Diagnosis and Medical Opinion

This is the most important section. The physician must state whether the miner has pneumoconiosis, whether it arose from coal-mine employment, and whether the miner is totally disabled from a respiratory standpoint. The opinion must be “documented and reasoned” under Director, OWCP v. Rowe. The consequence of a bare conclusion is that the ALJ can give it no weight. A misconception is that “I think he has black lung” is enough, but the physician must explain why based on the history, exam, and test results.

Section 10: Physician Signature and Credentials

The physician signs, dates, and lists board certifications, NIOSH B-reader number, and license. The consequence of an unsigned or undated form is automatic rejection. A misconception is that a physician assistant or nurse practitioner can sign for the doctor, but 20 C.F.R. § 718.104(a) requires a licensed physician’s signature.

Three Common Scenarios on CM-933b

The table below shows three of the most common fact patterns and how the physician’s entries on CM-933b drive the outcome.

Physician Entry	Claim Outcome
35 years underground, never smoked, FEV1 55% predicted, B-reader 1/1 simple pneumoconiosis, reasoned opinion linking impairment to coal dust	Benefits awarded under 15-year presumption; no rebuttal evidence overcomes a documented and reasoned report
18 years surface mining, 40 pack-year smoker, FEV1 62% predicted, X-ray 0/1 (negative), opinion attributes all disease to smoking	Benefits denied unless miner submits a second reasoned opinion finding legal pneumoconiosis under 20 C.F.R. § 718.201(a)(2)
22 years underground, 10 pack-year smoker, FEV1 48% predicted, B-reader 2/1, opinion explains additive effect of dust and smoke	Benefits awarded; legal pneumoconiosis established and total disability shown by qualifying spirometry

Named Examples: How Real Miners and Doctors Use CM-933b

Example 1: Earl in West Virginia

Earl worked 32 years as a roof bolter in southern West Virginia. He files a federal claim in March 2026. The DOL schedules a complete pulmonary evaluation with Dr. Patel. Dr. Patel completes CM-933b, lists Earl’s 32 years underground, his five pack-year smoking history that ended in 1992, his FEV1 of 51% predicted, and a B-reader interpretation of 1/2 simple pneumoconiosis. In Section 9, Dr. Patel writes a half-page narrative explaining that Earl’s impairment is consistent with coal workers’ pneumoconiosis and that his minimal smoking history does not account for the severity. The district director awards benefits four months later.

Example 2: Maria, Surviving Spouse in Pennsylvania

Maria’s husband Frank died in 2025 after 28 years in a Pennsylvania anthracite mine. She files a survivor’s claim under Section 422(l) of the Act. Because Frank was receiving federal Black Lung benefits at his death, Maria is automatically entitled under the Affordable Care Act amendment. CM-933b is not required for her claim, but Frank’s prior CM-933b from 2018 is pulled from the file and reaffirms entitlement.

Example 3: Jasper in Kentucky

Jasper is a 28-year Kentucky miner who smoked two packs a day for 30 years. Dr. Lee fills out CM-933b and concludes Jasper has COPD from smoking, not pneumoconiosis. Jasper hires a Black Lung representative who arranges a second opinion from Dr. Green. Dr. Green completes a supplemental CM-933b explaining that coal-mine dust and cigarette smoke act additively to cause obstructive lung disease, and that Jasper’s 28 years of dust exposure substantially contributed to his impairment. The ALJ credits Dr. Green’s reasoned opinion over Dr. Lee’s and awards benefits.

Mistakes to Avoid on CM-933b

Leaving the smoking history blank. The defense will argue the physician ignored a major alternative cause, and the report loses weight under § 718.104.
Writing a conclusory opinion. “Miner has black lung” without reasoning fails the Rowe standard and can be disregarded entirely.
Recording the wrong height. A two-inch error can flip qualifying spirometry to non-qualifying under Appendix B.
Skipping the exercise blood gas study. When resting values are non-qualifying, exercise testing is the miner’s last chance to prove disability under § 718.105.
Using a non-B-reader for the X-ray. The reading carries less weight, and the defense will exploit it on cross-examination.
Failing to address legal pneumoconiosis. Even if classical X-ray pneumoconiosis is absent, the physician should address whether coal dust caused or contributed to any chronic lung disease under § 718.201(a)(2).
Not signing or dating the form. An unsigned CM-933b is automatically rejected.
Forgetting to attach tracings. Spirometry tracings must be submitted with the form so a reviewer can confirm acceptable effort.
Misstating years of coal-mine employment. Underreporting years can cost the miner the 15-year presumption.
Using a nurse practitioner’s signature. Only a licensed physician can sign under § 718.104(a).

Do’s and Don’ts for Completing CM-933b

Do’s

Do request the DOL-paid complete pulmonary evaluation under 20 C.F.R. § 725.406, because it costs the miner nothing and produces a full record.
Do choose a board-certified pulmonologist when possible, because credentials drive evidentiary weight.
Do bring every prior medical record to the exam, because the physician must consider the miner’s full history.
Do confirm the X-ray reader is a NIOSH B-reader, because non-B-reader interpretations are easier to attack.
Do read the completed form before it is submitted, because typos in name, SSN, or claim number cause delays.

Don’ts

Don’t downplay symptoms. Honest, specific descriptions like “short of breath after 50 feet” are more persuasive than vague entries.
Don’t smoke before the spirometry. Recent smoking can artificially lower values and invite a non-conforming test challenge.
Don’t skip the blood gas study because of needle anxiety; the test is often outcome-determinative.
Don’t sign blank forms or let staff fill in medical opinions on the doctor’s behalf.
Don’t rely solely on CM-933b. Pair it with the employment history (CM-911a) and lay witness statements about dust exposure.

Pros and Cons of the DOL-Paid CM-933b Exam

Pros

The exam is free to the miner under Section 725.406.
The miner picks the physician from a DOL-approved list.
The report is presumed to meet the quality standards if performed correctly.
The DOL pays for the X-ray, spirometry, and blood gas tests.
The report becomes part of the official claim record at no cost.

Pros vs. Cons Table

Pros of DOL-Paid Exam	Cons or Limits of DOL-Paid Exam
No cost to the miner	The miner gets only one DOL-paid exam per claim
Miner chooses physician from approved list	Approved list may be limited in rural areas
Tests follow Part 718 quality standards	Coal company can submit competing exams
Report admitted automatically	A weak report can hurt the claim
Helps trigger 15-year presumption	Does not guarantee benefits without a reasoned opinion

Cons

Only one DOL-paid exam is allowed, so a weak first report cannot be redone at DOL expense.
The coal company is entitled to its own examination under 20 C.F.R. § 725.414.
A poorly written opinion can sink the claim.
Approved physicians may be hours away in rural mining communities.
The exam does not address dependents’ benefits, which require separate proof.

Key Entities Involved in CM-933b

The form sits in a web of agencies, statutes, and people. The Division of Coal Mine Workers’ Compensation administers the claim. The Office of Workers’ Compensation Programs is the parent office inside the DOL. The Office of Administrative Law Judges hears contested claims. The Benefits Review Board hears appeals from ALJ decisions. NIOSH certifies B-readers and publishes the Coal Workers’ Health Surveillance Program data. The coal mine operator, identified on Form CM-913, is the “responsible operator” who pays benefits if liable under 20 C.F.R. § 725.495.

Recap of Key Court Rulings

In Director, OWCP v. Rowe, 710 F.2d 251 (6th Cir. 1983), the Sixth Circuit set the “documented and reasoned” standard that still governs every CM-933b opinion. In Westmoreland Coal Co. v. Cochran, 718 F.3d 319 (4th Cir. 2013), the Fourth Circuit affirmed that a physician’s report addressing both clinical and legal pneumoconiosis carries strong weight. In Antelope Coal Co. v. Goodin, 743 F.3d 1331 (10th Cir. 2014), the Tenth Circuit upheld the 15-year presumption for surface miners with comparable dust exposure. In Mingo Logan Coal Co. v. Owens, 724 F.3d 550 (4th Cir. 2013), the court reinforced that an ALJ may credit a treating physician’s CM-933b over a one-time consultant’s report.

State Nuances on Top of Federal CM-933b

Federal Black Lung is uniform, but several states layer their own programs on top. West Virginia runs a state Occupational Pneumoconiosis Board that uses its own medical forms but accepts CM-933b as supporting evidence. Kentucky requires a separate state filing with its Department of Workers’ Claims and uses a different consensus-reading X-ray process. Virginia handles state coal workers’ pneumoconiosis claims through its Workers’ Compensation Commission. Pennsylvania treats anthracite-related disease under its Occupational Disease Act with its own medical forms.

The consequence of ignoring state programs is leaving money on the table, because state and federal benefits can sometimes stack subject to offset rules in 20 C.F.R. § 725.535. A misconception is that filing in one system bars the other, but most states allow concurrent filings.

FAQs

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

No. Form CM-933 is the Roentgenographic Interpretation for the chest X-ray reading, while CM-933b is the broader physician’s report covering history, exam, and pulmonary tests.

Can I get a copy of CM-933b online?

Yes. The DOL publishes Black Lung forms on the DCMWC compliance forms page, and the miner’s representative can also request copies from the district office.

Does the DOL pay for my CM-933b exam?

Yes. Under 20 C.F.R. § 725.406, every miner who files a claim is entitled to one complete pulmonary evaluation paid for by the Department of Labor.

Can a nurse practitioner sign CM-933b?

No. The quality standards at 20 C.F.R. § 718.104 require a licensed physician’s signature for the report to be valid.

Will a negative chest X-ray end my claim?

No. Pneumoconiosis can also be proven by biopsy, autopsy, the 15-year presumption, or a reasoned medical opinion under 20 C.F.R. § 718.202(a)(4).

Does smoking disqualify me from Black Lung benefits?

No. Legal pneumoconiosis under 20 C.F.R. § 718.201(a)(2) covers any chronic lung disease arising in part from coal-mine dust, even if smoking also contributed.

Can the coal company order its own exam?

Yes. Under 20 C.F.R. § 725.414, the responsible operator may submit its own medical evidence, usually a competing CM-933b from a company-selected pulmonologist.

Do surface miners qualify for CM-933b benefits?

Yes. Section 902(d) of the Act and the holding in Antelope Coal v. Goodin confirm that surface miners with comparable dust exposure qualify.

Is there a time limit to file my claim and CM-933b?

Yes. A miner must generally file within three years of a medical determination of total disability due to pneumoconiosis under 20 C.F.R. § 725.308.

Can I appeal if my CM-933b is rejected as non-conforming?

Yes. The miner can request a formal hearing before an Administrative Law Judge and submit a corrected or supplemental report under 20 C.F.R. § 725.456.

Does CM-933b apply to survivor claims?

No. Survivors generally rely on the miner’s prior medical record, but a fresh report can be submitted if the survivor must independently prove the miner died due to pneumoconiosis under 20 C.F.R. § 718.205.

Can I switch doctors after my CM-933b exam?

Yes. The miner may submit additional medical evidence from other physicians within the evidentiary limits in 20 C.F.R. § 725.414, though the DOL only pays for one complete evaluation.

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