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OMB No. 0920-0020
NIOSH
Coal Workers’ Health Surveillance Program
1000 Frederick Lane, M/S LB208
Morgantown, WV 26508
Instructions & Sample Test Report:
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Spirometry Facility Certification Form
Section 1 Facility
Facility Name __________________________ Telephone number _________________ Email __________________
Street Address ___________________________ City ________________ State ________ Zip Code ________ County _________________
Type of Facility (Mobile, Clinic, Private Office, Hospital) ___________________ How many spirometry tests per year? _____
Section 2 Spirometry System(s) * Items are required
Unit 1
A. Room number (if applicable) ……………………………..
B. Manufacturer * ………………………………...
C. Model *……………………………………………..
D. Serial # ……………………………………………………………...
E. Date acquired …………………………………………………….
F. Spirometer validation letter (attached)* ………………..
G. Spirometer automated quality control* ……………….
H. Calibration check available* ………………………………..
I. Graphical Displays
Volume-Time
1. Meets 2005 ATS/ERS Standards*
Volume-Time
2. Real-time during testing*
J. Test report for interpreter (sample attached)
Yes
K. Spirometry data file
1. Stores 2005 ATS/ERS parameters*
Yes
2. Stores all maneuvers
Yes
3. Electronic output format*
Unit 2
……………………..
……
……
…………………….
……………………
Yes ……………………..
Yes …………………….
Yes ……………………
Flow-Volume
Volume-Time
Flow-Volume
Flow-Volume
Volume-Time
Flow-Volume
Yes
Yes
If NO, max # ____
2005 ATS/ERS
………………………..
…..…..
.……….
………………………..
……………………….
……………
Yes
……………
Yes
…………….
Yes
Yes
NIOSH-approved
If NO, max # ____
2005 ATS/ERS
.
Section 3 Program and Staff Information
L. Spirometry procedure manual (available in lab)
Yes:mo/yr revised
M. Ongoing spirometry quality assurance program
Yes: mo/yr revised
…………….
…………….
N. Height measurement device
Stadiometer (brand)
Other
O. Weight measurement device
Medical scale (brand)
Other
P. Name(s) of spirometry technologist(s)
NIOSH-approved
Yes: mo/yr revised
Yes: mo/yr revised
Copy of NIOSH approved spirometry certificate attached?
Yes
Yes
Yes
Yes
Q. I agree to participate in this program in the manner specified by Part 37 of the Code of Federal Regulations (42 CFR Part 37), and understand that
all information used in connection with this program will be held STRICTLY CONFIDENTIAL and divulged only as specified by the above Regulation.
Supervising Clinician Name (copy of license attached)
Signature
Clinician certification or specialized spirometry training institution
Date
Title+ Date of course or certification
Clinician Email
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments
regard-ing this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports
Clearance Officer, 1600 Clifton Road, MS H21-8, Atlanta, GA, 30333, ATTN: PRA (0920-0020).
Email Form
CDC/NIOSH 2.14 (E), Rev. 03/2021
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File Type | application/pdf |
File Title | Spirometry Facility Certification Form |
Subject | Spirometry,Facility,Certification,Form, tgd2 |
Author | DHHS/CDC/OD/OCOO/OCIO/MASO |
File Modified | 2025-01-16 |
File Created | 2014-08-15 |