0920-24IK Spirometry-Facility-Certification-Form

Form Approved
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).

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CDC/NIOSH 2.14 (E), Rev. 03/2021

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