CM-1159 Report of Arterial Blood Gas Study

Claim adjudication process for alleged presence of pneumoconiosis

CM-1159 June 2008

Roentgenographic Interpretation (CM-933), Roentgenographic Quality Rereading (CM-933b), Medical History and Examination for Coal Mine Workers' Pneumoconiosis (CM-988), Report of....

OMB: 1215-0090

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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.

  1. Name of Miner (First, middle, last)



  1. SSN or DOL Claim No.



  1. Date of Test (mm/dd/yyyy)


  1. Miner’s:

_______________ Age

_______________ Height

_______________ Weight


  1. Altitude: (Check one)

  0 to 2999 feet above sea level

 3000 to 5999 feet above sea level

 6000 feet or more above sea level

  1. 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:*_________ ________ ________ ______________

  1. Pulse rate at time sample drawn:


Rest: _____________ Exercise: ______________


  1. 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:

  1. 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.

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File Modified2008-08-21
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