Report of Ventilatory Study

U.S. Department of Labor

Report of Ventilatory Study

Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

Note: This report is authorized by law (30 USC, 901 at. seq.) and required to obtain a benefit. The results of this interpretation
will aid in determining the miner's eligibility for black lung benefits. Disclosure of a Social Security Number is voluntary. The
failure to disclose such number will not result in the denial of any right, benefit, or privilege to which the claimant may be
entitled. This method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974, and
OMB Circular No. 108.

OMB No. 1215-0090
Expires: 07-31-2008

Instructions: Any ventilatory study conducted after January 19, 2001 must include tracings of flow versus volume (flow-volume loop) as part
of the reported test. If the spirometer used for this test cannot provide a flow-volume loop, indicate this fact in item 10. Submit three tracings of
the flow-volume loop which displays the entire maximum inspiration and the entire maximum forced expiration, and three tracings of the volume
versus time (spirogram) derived electronically from the flow-volume loop. Identify each tracing with the patients name and social security
number/DOL Claim Number. Report the results of the FEV1, the FVC and the FEV1/FVC ratio (expressed as a percentage). If a bronchodilator is
administered, report the values obtained both before and after bronchodilation and explain the significance of the results obtained in item 10.
Measuring and reporting the MVV optional. If the MVV is measured, submit two tracings of the individual breath volumes versus time if the MVV
values obtained are within 10% of each other; otherwise, submit three tracings. The MVV results must be obtained independently, rather than
calculated from the FEV1. Complete instructions and standards for administration of these tests may be found in 20 CFR Part 718, Subpart B,
718.103, and Appendix B, and are summarized on Form CM-2954a.
1. Name of Miner (First, middle, last)

2. Social Security Number or DOL
Claim Number:

3. Date and Time of Test

:
MM

4. Age:

5. Sex:

6. Height(inches):

7. Weight:

9. (a) Type of Test

DD

YY

p.m.

a.m.

8. Circle as appropriate (If ''poor'', explain in No. 10, ''Additional Comments'', the nature
and extent of any impact this factor had on the results obtained)

(b) Observed Values
BEFORE Bronchodilator
(Corrected to BTPS)

Miner's degree of Cooperation:

Good

Fair

Poor

Miner's ability to understand instructions
and follow directions:

Good

Fair

Poor

Observed Values
AFTER Bronchodilator, if Given
(Corrected to BTPS)

(c) Predicted Normal Values

FEV1 (In liters/second)
(Required)
FVC (In liters)
(Required)
FEV1 /FVC Ratio)
(Required)
MVV (In liters/minute)
(Optional)
10. Additional Comments: (For example - note any dyspnea; use of bronchodilators; coughing during test;
If the miner was unable to complete the test, explain reason for such failure.)
11. (a) Type of machine used (Trade name)
12. Facility where test performed

(b) Rate of paper speed

(c) Temperature of Equipment

13. Print or type Name and Title of Technician or Physician
administering test

I certify that these ventilatory studies were conducted and reported in compliance with specifications and instructions provided by the Department
of Labor. I also certify that the information furnished is correct and I am aware that my signature attests to the accuracy of the results reported. I am
aware that any person who willfully makes any false or misleading statement or representation in support of an application for benefits shall be
guilty under Title 30 USC 941 of a misdemeanor and subject to a fine of up to $1,000., or to imprisonment for up to one year, or both.

Print or Type Name of Physician

Physician's Signature

Date

Public Burden Statement
We estimate that it will take an average of 20 minutes to complete this collection of information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
If you have any comments regarding the burden estimate or any other aspect to this collection of information, including suggestions for
reducing this burden, send them to the Division of Coal Mine Workers' Compensation, U.S. Department of Labor, Room N-3464, 200
Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
Form CM-2907
Rev. Dec. 2001