CM-1159 Report of Arterial Blood Gas Study

Report of Arterial Blood Gas Study				U.S. DEPARTMENT OF LABOR Employment Standards Administration Office of Workers’ Compensation Programs Division of Coal Mine Workers’ Compensation
This report is authorized by law (30 USC 901 et. 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: Summarized below are the procedures to be followed in administering this test. The arterial blood gas study shall initially be administered at rest and in a sitting position. If the results of the test at rest are not within the values indicated on the applicable table shown on the reverse side of this form, an exercise blood-gas study shall be offered to the miner unless medically contraindicated. *If an exercise blood gas test is administered, blood shall be drawn during exercise. Complete instructions for administration of this test and table of values may be found in 20 CFR Part 718, Subpart B, 718.105, and appendix C.
Name of Miner (First, middle, last)			SSN or DOL Claim No.					Date of Test (mm/dd/yyyy)
Miner’s: _______________ Age _______________ Height _______________ Weight		Altitude: (Check one)   0 to 2999 feet above sea level  3000 to 5999 feet above sea level  6000 feet or more above sea level					Barometric Pressure _____________________________________ Equipment Temperature __________________________________ Cº
7. Site of Puncture: ________________ Indwelling line: ________________ Single stick: _________________
8a. Time Sample Iced Time Sample Drawn Yes No Analyzed Rest: ____________ ________ ________ ______________ Exercise:*_________ ________ ________ ______________						Pulse rate at time sample drawn: Rest: _____________ Exercise: ______________ Was equipment calibrated before and after each test?  Yes  No
d. Type of exercise and duration: *
9. Test Results	Predicted Normal Range					Observed Values
						Resting			Exercise if Administered *
pCO2 (mmHg)
pO2 (mmHg)
pH
* Is the exercise portion of this study medically contraindicated?  Yes  No If YES, for what reason?
10. Additional Comments:
11a. Facility where test performed: 11b. Provider Number:					Print or type name of technician performing the study:
					13. Print or type the name of the physician:
14. Physician’s Signature: I certify that the information furnished is correct and am aware that my signature attests to the accuracy of the results reported. I am also aware than any person who willfully makes any false or misleading statement or representation in support of an application for benefits shall be guilty under 30 USC 941 of a misdemeanor and subject to a fine of up to $1000, or imprisonment for up to one year, or both. Signature: Date:

Form CM-1159

Rev. June 2008

Blood Gas Tables

The following tables set forth the values to be applied in determining whether total disability may be established in accordance with the criteria contained in 20 CFR 718.

(1) For arterial blood gas studies performed at test sites up to 2,999 feet above sea level:							(2) For arterial blood gas studies performed at test sites 3,000 to 5,999 feet above sea level:
Arterial pCO2 (mmHg) Arterial pO2 equal to or less than (mmHg)							Arterial pCO2 (mmHg) Arterial pO2 equal to or less than (mmHg)
25 or below					75		25 or below				70
26					74		26				69
27					73		27				68
28					72		28				67
29					71		29				66
30					70		30				65
31					69		31				64
32					68		32				63
33					67		33				62
34					66		34				61
35					65		35				60
36					64		36				59
37					63		37				58
38					62		38				57
39					61		39				56
40-49					60		40-49				55
50 and above					(1)		50 and above				(2)

¹ Any Value ² Any Value

(3) For arterial blood gas studies performed at test sites 6,000 feet or more above sea level:
Arterial pCO2 (mmHg) Arterial pO2 equal to or less than (mmHg)
25					65
26					64
27					63
28					62
29					61
30					60
31					59
32					58
33					57
34					56
35					55
36					54
37					53
38					52
39					51
40-49					50
50 and above					(3)

³Any Value

Public Burden Statement

We estimate that it will take an average of 15 minutes to complete this information collection including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding these estimates or any other aspect of this survey, 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, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

Note: Persons are not required to complete this collection of information unless it displays a currently valid OMB control number.