Chest X-ray classification requirements

Only physicians with specific qualifications may classify chest X-rays for pneumoconioses. Appendix E to the asbestos-in-construction standard requires that all X-rays be classified only by a B-Reader, a board eligible or board certified radiologist, or an experienced physician with known expertise in pneumoconioses 1926.1101(Appendix E).

• This is a mandatory requirement under the asbestos standard 1926.1101.
• Employers should confirm the classifier’s credentials (e.g., B-Reader certification or documented experience) before relying on the classification.

Chest X-rays must be classified using the ILO International Classification of Radiographs of Pneumoconioses (revised edition 2011). Appendix E mandates classification in accordance with the Guidelines for the use of the ILO International Classification of Radiographs of Pneumoconioses (revised edition 2011) 1926.1101(Appendix E).

• The ILO edition is incorporated by reference as required by the regulation (see the incorporation reference in 1926.6).
• Employers and classifiers must use the ILO 2011 guidelines as the authoritative standard for reading and recording pneumoconiosis findings.

Chest X-ray classifications must be recorded on a classification form following the CDC/NIOSH (M) 2.8 format, and at minimum the content within the bold lines of that form (items 1 through 4) must be included. Appendix E requires use of the CDC/NIOSH (M) 2.8 form format and specifies that items 1–4 (the content within the bold lines) are the minimum required entries 1926.1101(Appendix E).

• The form used for recording is not to be submitted to NIOSH, per Appendix E.
• Employers should obtain the CDC/NIOSH (M) 2.8 form to ensure they capture the required minimum information.

No, the CDC/NIOSH (M) 2.8 classification form is not to be submitted to NIOSH. Appendix E explicitly states that clinicians should record classifications on the CDC/NIOSH (M) 2.8 form but that the form is not to be submitted to NIOSH 1926.1101(Appendix E).

• Employers still must retain required medical records and classifications in accordance with applicable medical surveillance provisions of 1926.1101.
• Do not send the M 2.8 forms to NIOSH unless other programs or agreements explicitly require submission.

A complete set of the ILO standard format radiographs must be immediately available for reference when classifying film chest X-rays. Appendix E requires that physicians have the ILO standard format radiographs (for use with the ILO Guidelines, revised edition 2011) immediately available when classifying film radiographs 1926.1101(Appendix E).

• This ensures consistent comparison against the ILO standard images while performing the classification.
• The requirement applies specifically when classifying film (non-digital) X-rays.

For digitally-acquired chest X-rays, a physician must have immediately available a complete set of ILO standard digital chest radiographic images for reference. Appendix E requires availability of the ILO digital images provided for use with the ILO Guidelines (revised edition 2011) when classifying digital radiographs 1926.1101(Appendix E).

• The digital ILO reference images should be accessible while the classifier reviews the electronic images.
• Having the appropriate ILO digital reference set available supports consistent and accurate digital-image classification.

No, digitally-acquired chest X-rays must be classified from electronic copies and not from hard-copy printed transparencies. Appendix E explicitly states that classification of digitally-acquired chest X-rays shall be based on viewing images displayed as electronic copies and shall not be based on viewing hard copy printed transparencies of images 1926.1101(Appendix E).

• If the image was captured digitally, the classifier should view the image on an appropriate electronic display rather than a printed transparency.
• This requirement helps preserve the fidelity and diagnostic detail of digital radiographs during classification.

Yes, a board eligible radiologist is explicitly allowed to classify chest X-rays under Appendix E. The appendix lists "a B-Reader, a board eligible/certified radiologist, or an experienced physician with known expertise in pneumoconioses" as acceptable classifiers 1926.1101(Appendix E).

• Employers should document the radiologist’s credentials to confirm they meet the appendix’s requirement.
• If in doubt about qualifications or experience, employers may prefer a certified B-Reader or an experienced pneumoconioses physician for consistency.

No, Appendix E requires that classifications be performed by qualified physicians or B-Readers; it does not authorize non-physician health professionals to perform the classification. Appendix E specifies classification only by a B-Reader, a board eligible/certified radiologist, or an experienced physician with known expertise in pneumoconioses 1926.1101(Appendix E).

• Non-physician technicians or staff may assist in image acquisition or administrative tasks, but not in the formal classification required by the standard.
• Employers should ensure that only appropriately qualified clinicians sign and record the classification results.

Yes, if the remediation work involves asbestos-containing building materials, the employer must comply with the asbestos-in-construction standard, including Appendix E chest X-ray classification requirements. OSHA has stated that remediation activities involving ACBM are covered by 29 CFR 1926.1101 (the construction asbestos standard), so the medical surveillance provisions in that standard—including Appendix E for chest X-ray classification—apply to such employers Asbestos remediation protocols (OSHA Letter of Interpretation, Nov. 14, 2024) and 1926.1101(Appendix E).

• Property remediation firms that perform asbestos-related work on residences or other buildings should treat those activities as construction work for the purpose of asbestos compliance.
• Medical surveillance requirements (including correctly classified chest X-rays) should be part of the employer’s asbestos program when employees are exposed to ACBM.

Remote electronic access is acceptable provided the physician has the complete set of ILO reference images immediately available at the time of classification. Appendix E requires that the physician have the ILO standard digital chest radiographic images immediately available for reference when classifying digitally-acquired chest X-rays, but it does not limit the reference set to local physical storage, so secure immediate electronic access meets the requirement 1926.1101(Appendix E).

• "Immediately available" means the classifier must be able to view the ILO digital reference images at the same time they are interpreting the electronic chest X-rays.
• Employers should ensure reliable, secure access to the ILO digital reference set (for example, via a secure image server) for remote classifiers.

Yes, Appendix E requires that classification be done using the appropriate ILO reference format for the medium being viewed; if film X-rays are digitized and presented as electronic images, the classifier must have and use the ILO digital reference images and classify the images as electronic copies. Appendix E distinguishes classification of film (which requires ILO film format references) from classification of digitally-acquired images (which requires ILO digital references and electronic viewing) 1926.1101(Appendix E).

• If the original was film but the classifier is viewing it as an electronic file, they must follow the digital-image rules (use ILO digital reference set and view electronic copies).
• Ensure digitization preserves image quality and that the classifier is using the correct ILO reference format for consistent comparison.

No, Appendix E mandates classification in accordance with the ILO International Classification of Radiographs of Pneumoconioses (revised edition 2011); other classification systems do not satisfy this requirement for compliance. Appendix E states that chest X-rays shall be classified in accordance with the ILO 2011 Guidelines 1926.1101(Appendix E).

• Employers should not rely on alternate classification schemes if they are subject to 1926.1101’s Appendix E requirements.
• Using the ILO 2011 system helps ensure consistent, nationally accepted readings across clinicians and programs.

Appendix E does not specify record retention periods for the CDC/NIOSH (M) 2.8 classification form; it only prescribes the form format and that it not be submitted to NIOSH. Appendix E instructs that chest X-rays shall be classified in accordance with the ILO Guidelines and recorded on the CDC/NIOSH (M) 2.8 form (items 1–4 minimum) and states that this form is not to be submitted to NIOSH, but retention and recordkeeping requirements are addressed elsewhere in 1926.1101 and other applicable medical recordkeeping rules 1926.1101(Appendix E).

• Employers should follow the medical record retention and confidentiality provisions found in the broader 1926.1101 and applicable OSHA recordkeeping rules.
• When managing records, confirm retention periods and access rules with the medical program provider and legal/regulatory guidance for medical surveillance records.

No, Appendix E requires active classification by a qualified clinician with the appropriate ILO references immediately available; the classification should be performed by the named classifier at the time of review rather than simply relying on an undocumented prior opinion. Appendix E requires that chest X-rays be classified in accordance with the ILO Guidelines and recorded on the CDC/NIOSH (M) 2.8 form by a qualified classifier who has the ILO references available 1926.1101(Appendix E).

• If an employer relies on a prior classification, ensure the prior reading was performed by an acceptable classifier and was documented using the required form and references.
• Best practice is to have the current, qualified clinician review the image and complete the required M 2.8 entries when medical surveillance actions depend on current interpretation.

No, Appendix E requires the appropriate ILO reference format for each imaging medium: ILO standard format radiographs for film and ILO standard digital chest radiographic images for digitally-acquired X-rays. Appendix E explicitly differentiates the required reference sets for film versus digitally-acquired images and requires that digital images be classified using electronic copies, not printed transparencies 1926.1101(Appendix E).

• Use the ILO film standard images when reading traditional film radiographs.
• Use the ILO digital standard images and electronic viewing when reading digital chest radiographs.

Employers should provide secure, reliable access to the complete set of ILO reference images (film or digital, as appropriate) so the classifier can view them at the time of interpretation. Appendix E requires that the physician have the appropriate ILO standard references immediately available when classifying either film or digitally-acquired chest X-rays 1926.1101(Appendix E).

• For film readings, keep an accessible set of the ILO standard format radiographs in the reading area.
• For digital readings, ensure the ILO digital reference images are accessible on the same electronic system or via a secure server so the classifier can view them concurrently with the patient images.
• Document access arrangements in the medical surveillance program so classifiers and employers understand how the references will be made available.

Yes, OSHA has letters of interpretation that clarify application of the asbestos standard to remediation activities and related requirements. For example, OSHA’s letter addressing asbestos remediation protocols explains that remediation activities involving asbestos-containing building materials are covered by the construction asbestos standard, 29 CFR 1926.1101, and that those employers must follow its requirements Asbestos remediation protocols (OSHA Letter of Interpretation, Nov. 14, 2024). Appendix E’s chest X-ray classification rules are part of the medical surveillance framework in that same standard 1926.1101(Appendix E).

• Use the OSHA interpretation to determine whether a remediation employer falls under 1926.1101 and therefore must follow medical surveillance and classification requirements.
• When in doubt, consult OSHA guidance or the Directorate of Enforcement Programs for application questions to specific work contexts.

Yes, the classifier must have the ILO digital reference images immediately available while viewing the electronic chest X-rays, regardless of which electronic system the images are on. Appendix E requires that digitally-acquired chest X-rays be classified based on viewing electronic copies and that the complete set of ILO digital reference images be immediately available for reference during classification 1926.1101(Appendix E).

• Ensure that the electronic system used to view transferred images can also display or provide prompt access to the ILO digital reference images.
• Confirm image quality and display settings on the receiving system so the classifier can make an accurate interpretation using the ILO references.