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UNITED STATES DEPARTMENT OF LABOR OFFICE OF ADMINISTRATIVE (Department of Labor)

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(01/2003) USDOL/OALJ BLBA Evidence Summary
Page 1 of 7
UNITED 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 Employer 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:
(01/2003) USDOL/OALJ BLBA Evidence Summary
Page 2 of 7
I. 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).
Exhibit No. Physician
B-Reader (B)/
Board Cert. (BCR)
Date of
X-ray study
Date of
Reading Film Quality Reading
OWCP Evaluation. The Department is required to provide the miner with a chest x-ray 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 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 originally interpreted the chest X-ray.”
20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit No. Physician Date of Report
Rehabilitation
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 physician’s interpretation of each chest x-ray
study submitted by opposing party. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit No. Physician
B-Reader (B)/
Board Cert. (BCR)
Date of
X-ray study
Date of
Reading Film Quality Reading
For rebuttal of Department-sponsored chest x-ray study only.
(01/2003) USDOL/OALJ BLBA Evidence Summary
Page 3 of 7
II. Pulmonary function studies
A. Initial evidence. A party may submit the results of no more than two pulmonary function studies in
support of its position. 20 C.F.R. § 725.414(a)(2)(i) and (3)(i) (2001).
Exhibit
No. Physician
Date of
study
Tracings
present?
Flow-
volume
loop?
Broncho-
dilator? FEV1
FVC/
MVV
Coop. and
Comp.
Noted?
OWCP Evaluation. The Department is required to provide the miner with a pulmonary function 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 “tends to
undermine” a specific pulmonary function study exhibit set forth above. 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. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit
No. Physician Date of Report
Rehabilitation
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 physician’s 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
No. Physician Date of Report
Rebuttal of
Exhibit No. Comments
For rebuttal of Department-sponsored pulmonary function study only.
(01/2003) USDOL/OALJ BLBA Evidence Summary
Page 4 of 7
III. 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
No. Physician
Date of
Study Altitude
Resting(R)
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 “tends to
undermine” a specific blood gas study set forth above. In such a case, the proponent of the blood gas
study exhibit “shall be entitled to submit an additional statement from the physician who . . . administered
the objective testing.” 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit
No. Physician Date of Report
Rehabilitation
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 physician’s assessment of each blood gas study
offered by the opposing party. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit
No. Physician Date of Report
Rebuttal of
Exhibit No. Comments
For rebuttal of Department-sponsored blood gas study only.
(01/2003) USDOL/OALJ BLBA Evidence Summary
Page 5 of 7
IV. Medical reports
The parties are notified that “medical reports” may only be based on medical evidence which is admissible consistent with
the 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 physician’s written assessment of the miner’s respiratory or pulmonary condition. A medical report may
be prepared by the physician who examined the miner and/or reviewed the available admissible evidence.
A physician’s 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 section.
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).
Exhibit No. Physician
Date of
Medical Report Comments
OWCP Evaluation. The Department is required to provide the miner with a complete pulmonary evaluation.
20 C.F.R. § 725.406(a) (2001).
B. Rehabilitative evidence is permitted ONLY if opposing party has presented “rebuttal evidence” which
“tends to undermine” the conclusion of a physician who prepared one of the above-listed medical reports. It
is noted that “rebuttal evidence” may consist of “no more than one physician’s interpretation of each chest
X-ray, pulmonary function test, blood gas study, autopsy or biopsy” submitted by the opposing party. In
such a case, the proponent is entitled to submit an “additional statement” from the physician who prepared
the medical report explaining his or her conclusion in light of the rebuttal evidence. 20 C.F.R. §
725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit No. Physician
Date of
Report
Rehabilitation
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 medical opinion.
(01/2003) USDOL/OALJ BLBA Evidence Summary
Page 6 of 7
V. Autopsy evidence
A. Initial evidence. A party may submit no more than one autopsy report in support of its position. 20
C.F.R. § 725.414(a)(2)(i) and (3)(i) (2001).
Exhibit
No. Physician
Date of
Autopsy Report Comments
B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which “tends to
undermine” the autopsy report. In such a case, the proponent of the report shall be entitled to submit an
“additional statement” from the physician who prepared the autopsy report explaining his or her conclusions
in light of the rebuttal evidence. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit
No. Physician Date of Report
Rehabilitation
of Exhibit No. Comments
C. Rebuttal evidence. A party may offer no more than one physician’s interpretation of the opposing party’s
autopsy report. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit
No. Physician Date of Report
Rebuttal of
Report Dated: Comments
VI. Biopsy evidence
A. Initial evidence. A party may submit no more than one report of each biopsy in support of its position.
20 C.F.R. § 725.414(a)(2)(i) and (3)(i) (2001).
Exhibit
No.
Physician Date of Biopsy
Report
Comments
B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which “tends to
undermine” a particular biopsy report. In such a case, the proponent of the report shall be entitled to submit
an “additional statement” from the physician who prepared the biopsy report explaining his or her
conclusions in light of the rebuttal evidence. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit
No. Physician Date of Report
Rehabilitation
of Exhibit No. Comments
C. Rebuttal evidence. A party may offer no more than one physician’s interpretation of each biopsy report
submitted by the opposing party. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit
No. Physician Date of Report
Rebuttal of
Report Dated: Comments
(01/2003) USDOL/OALJ BLBA Evidence Summary
Page 7 of 7
VII.
“Other medical evidence” under § 718.107
A. Initial evidence. A party may submit “other medical evidence” under § 718.107, such as CT-scans, and
“[t]he party submitting the test or procedure . . . bears the burden to demonstrate that the test or procedure
is medically acceptable and relevant to establishing or refuting a claimant’s entitlement to benefits.” 20
C.F.R. § 718.107(b) (2001).
Exhibit
No. Physician Type of Record
Date of
Activity Comments
B. Rehabilitative evidence is permitted ONLY if opposing party has presented evidence which “tends to
undermine” a specific test or study set forth above. In such a case, the proponent of the study or test “shall
be entitled to submit an additional statement from the physician who . . . administered the objective
testing.” 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit
No. Physician Date of Report
Rehabilitation
of Exhibit No. Comments
C. Rebuttal evidence. A party may offer no more than one physician’s assessment of each test or study
offered by the opposing party. 20 C.F.R. § 725.414(a)(2)(ii) and (3)(ii) (2001).
Exhibit
No. Physician Date of Report
Rebuttal of
Exhibit No. Comments
VIII. Hospitalization records and treatment notes
The amended regulations provide that, notwithstanding the evidentiary limitations contained at 20 C.F.R. § 725.414(a)(2) and
(a)(3), “any record of a miner’s hospitalization for a respiratory or pulmonary or related disease may be received into
evidence.” 20 C.F.R. § 725.414(a)(4) (2001).
Exhibit
No.
Beginning and Ending Dates of
Hospitalization/
Treatment
Name of
Hospital/Physician Nature of Treatment
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UNITED STATES DEPARTMENT OF LABOR OFFICE OF ADMINISTRATIVE (Department of Labor)

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Completed 26 January 2021

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