Black Lung Benefits Act Evidence Summary Form (OALJ)

(01/2003) USDOL/OALJ BLBA Evidence Summary Page 1 of 7UNITED STATES DEPARTMENT OF LABOR OFFICE OF ADMINISTRATIVE LAW JUDGES BLACK LUNG BENEFITS ACT EVIDENCE SUMMARY FORM Case Name: Case No. : Evidence submitted in support of position of: Claimant Emp loyer Director (check one) Signature of submitter: Address of submitter: s / ^ Signature of Representative, Attorney, or Party ^ Printed Name of Representative, Attorney, or Party Phone: Fax: Date of this submission: American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2(01/2003) USDOL/OALJ BLBA Evidence Summary Page 2 of 7I. Chest x-ray evidence A. Initial evidence. A party may submit no more than two chest x-ray interpretations in support of its position. 20 C.F.R. 725.414(a)(2)(i) and (3)(i) (2001) . B-Reader (B)/ Date of Date of Exhibit No. Physician Board Cert. (BCR) X-ray study Reading Film Quality Reading OWCP Evaluation. The Department is required to provide the miner with a chest x-ray stu dy as part of the complete pulmonary evaluation. 20 C.F.R. 725.406(a) (2001). B. Rehabilitative evidence is permitted ONLY if opposing party has presented a rereading which tends to undermine a specific x-ray exhibit set forth above. In such a case, the proponent of the x-ray exhibit shall be entitled to submit an additional statement from the physician who ori ginally interpreted the chest X-ray. 20 C.F.R. 725.414(a)(2)(ii) and (3)(ii) (2001). Rehabilitation Exhibit No. Physician Date of Report of Exhibit No. Comments For use by the Director only. The Director may submit rehabilitative evidence if any party submits evidence which tends to undermine the findings of the Department -sponsored chest x-ray study. C. Rebuttal evidence. A party may offer no more than one physicians interpretation of each chest x-ray study submitted by opposing party. 20 C.F.R. 725.414(a)(2)(ii) an d (3)(ii) (2001). B-Reader (B)/ Date of Date of Exhibit No. Physician Board Cert. (BCR) X-ray study Reading Film Quality Reading For rebuttal of Department-sponsored chest x-ray study only. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3(01/2003) USDOL/OALJ BLBA Evidence Summary Page 3 of 7II. Pulmonary function studies A. Initial evidence. A party may submit the results of no more than two pulmonary functio n studies in support of its position. 20 C.F.R. 725.414(a)(2)(i) and (3) (i) (2001). Flow- Coop. and Exhibit Date of Tracings volume Broncho- FVC/ Comp. No. Physician study present? loop? dilator? FEV1 MVV Noted? OWCP Evaluation. The Department is required to provide the miner with a pulmonary funct ion study as part of the complete pulmonary evaluation. 20 C.F.R. 725.406(a)( 2001). B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which te nds to undermine a specific pulmonary function study exhibit set forth abov e. In such a case, the proponent of the pulmonary function study exhibit shall be entitled to submit an additional statement from the physician who . . . administered the objective testing. 20 C.F.R. 725.41 4(a)(2)(ii) and (3)(ii) (2001). Exhibit Rehabilitation No. Physician Date of Report of Exhibit No. Comments For use by the Director only. The Director may submit rehabilitative evidence if any party submits evidence which tends to undermine the findings of the Department -sponsored pulmonary function study. C. Rebuttal evidence. A party may offer no more than one physicians assessment of each pulmonary function study offered by the opposing party. 20 C.F.R. 725.414(a )(2)(ii) and (3)(ii) (2001). Exhibit Rebuttal of No. Physician Date of Report Exhibit No. Comments For rebuttal of Department-sponsored pulmonary function study only. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4(01/2003) USDOL/OALJ BLBA Evidence Summary Page 4 of 7III. Blood gas studies A. Initial evidence. A party may submit the results of no more than two blood gas studies in support of its position. 20 C.F.R. 725.414(a)(2)(i) and (3)(i) (2001). Exhibit Date of Resting(R) No. Physician Study Altitude Exercise(E) PCO2 PO2 Comments OWCP Evaluation. The Department may provide the miner with a blood gas study as part of the complete pulmonary evaluation. 20 C.F.R. 725.406(a) (2001). B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which te nds to undermine a specific blood gas study set forth above. In such a cas e, the proponent of the blood gas study exhibit shall be entitled to submit an additional statement fr om the physician who . . . administered the objective testing. 20 C.F.R. 725.414(a)(2)(ii) and ( 3)(ii) (2001). Exhibit Rehabilitation No. Physician Date of Report of Exhibit No. Comments For use by the Director only. The Director may submit rehabilitative evidence if any party submits evidence which tends to undermine the findings of the Department -sponsored blood gas study. C. Rebuttal evidence. A party may offer no more than one physicians assessment of each blood gas study offered by the opposing party. 20 C.F.R. 725.414(a)(2)(ii) a nd (3)(ii) (2001). Exhibit Rebuttal of No. Physician Date of Report Exhibit No. Comments For rebuttal of Department-sponsored blood gas study only. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 5(01/2003) USDOL/OALJ BLBA Evidence Summary Page 5 of 7IV. Medical reports The parties are notified that medical reports may only be based on medical evidence which is admissible consistent withthe evidentiary limitations at 20 C.F.R. 725.414(a)(2)(i), ( 3)(i), and (c) (2001). 20 C.F.R. 725.414(a)(2)(i) and 725.457(d)(2001). Medical reports are defined in the regulations as: A physicians written assessment of the miners respiratory or pul monary condition. A medical report may be prepared by the physician who examined the miner and/or reviewed the available admissible evidence. A physicians written assessment of a single objective test, such as a chest X-ray or a pulmonary function test, shall not be considered a medical report for purposes of this sect ion. 20 C.F.R. 725.414(a)(1) (2001). A. Initial evidence. A party may submit no more than two medical reports in support of its position. 20 C.F.R. 725.414(a)(2)(i) and (3)(i) (2001). Date of Exhibit No. Physician Medical Report Comments OWCP Evaluation. The Department is required to provide the miner with a complete pulmonar y evaluation. 20 C.F.R. 725.406(a) (2001). B. Rehabilitative evidence is permitted ONLY