0920-24IK Spirometry Results

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Spirometry Results Notification Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION NATIONAL
INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
COAL WORKERS' HEALTH SURVEILLANCE PROGRAM (CWHSP)

SPIROMETRY FACILITY NAME

Form Approved
OMB No. 0920-0020

NIOSH
Coal Workers’ Health Surveillance Program
1000 Frederick Lane M/S LB208
Morgantown, WV 26508
FACILITY #

MINER’S NAME (LAST, FIRST, MIDDLE INITIAL)

MINER’S EMAIL ADDRESS

SPIROMETER UNIT #

MINER’S SOCIAL SECURITY NUMBER
Full SSN is optional; last 4 digits are required

DATE OF BIRTH
Sex
M

RACE AND/OR Ethnicity (check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Middle Eastern or North African
Native Hawaiian or Pacific Islander

F

MINER’S HEIGHT (stocking feet)

Hispanic or Latino
White
Other:______________

cm or

inches

MINER’S WEIGHT (stocking feet)
kg or
BLOOD PRESSURE
(resting)

pounds
HEART RATE
(resting)

/
SPIROMETRY TECHNICIAN NUMBER

SPIROMETRY TEST DATE

SPIROMETER CALIBRATION CHECK DATE

TEST ROOM CONDITIONS
Temp
C
F
Barometric Press
mmHg
Relative Humidity
%

TESTING POSITION
Standing
Seated

 Electronic copies of the volume-time and flow-volume
curves for the trials below are included with this form.

Spirometry Pre-Test Checklist
Yes

No

For items 1 – 6, review “Yes” responses with supervising clinician before
testing.

1. Systolic BP >160; Diastolic BP >100; or Pulse rate is >110 beats per
minutes. If yes, review with supervising clinician before testing.
2. Have you had any surgeries on your chest, abdomen, head, or eye
(including Lasik) or had a heart attack or stroke in the last 6 weeks? If yes,
consult supervising clinician before testing and consider reschedule after 68 weeks.
3. Have you had a cold, flu, or respiratory infection in your chest within the
last 3 weeks? If yes and symptoms still persist, consider reschedule in 6
weeks.
4. Have you ever been told by a doctor that you have an aneurysm or a
weakness in a major blood vessel? If yes, consult supervising clinician
before testing.
CDC/NIOSH 2.15 (E), Revised April 2016, CDC Adobe Acrobat 11.0, S508 Electronic Version, April 2016

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Yes

No
5. Have you ever had a collapsed lung (pneumothorax)? If yes, consult
supervising clinician before testing.
6. Have you coughed up any blood of unknown origin within the past 6
weeks? If yes, review with supervising clinician before testing.
7. Have you eaten a heavy meal within the last hour? If yes, try to wait 1
hour before testing.
8. Have you smoked within the last hour? If yes, try to wait 1 hour before
testing.

The certified spirometry clinic must record the spirometry results below if an electronic
spirometry record is not submitted to NIOSH. The printed spirometry report must also be
submitted with the results below or an electronic record.
SPIROMETRY TEST RESULTS *
Trial #
FVC (L)
FEV1 (L)
FEV6 (L)
Peak Expiratory Flow (L/s)
Extrapolated Volume (L)
(Vext or BEV)
Forced Expiratory Time (s)
Technician’s Evaluation of Miner’s Effort

Maximal

Sub-maximal

Uncertain

*Report results from 3 trials, which include the highest and second highest FVC and FEV1 values and the highest
Peak Expiratory Flow value, from among all acceptable curves.
Please indicate when data was transmitted to NIOSH (MM/DD/YYYY):
FAX Date

Mail Date

Electronic Date

Component Transmitted
Respiratory Assessment Form
Spirometry Results Notification
Form
Printed Spirometry Report
(Including Calibration Report)
Electronic Spirometry Results

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 regarding 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, Georgia 30333; ATTN: PRA (0920-0020).

CDC/NIOSH 2.15 (E), Revised April 2016, CDC Adobe Acrobat 11.0, S508 Electronic Version, April 2016

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