Report of Ventilatory Study |
U.S. Department of Labor Office of Workers’ Compensation Programs Division of Coal Mine Workers’ Compensation |
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Note: This report is authorized by law (30 U.S.C. 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. 1240-0023 Expires xx-xx-xxxx |
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Instructions: Any ventilatory study 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 patient’s name and social security number/DOL Claim Number. Report the results of the FEV1, the FVC and the FEVI/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 is 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. |
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_____________ _________:________ MM DD YY a.m. p.m. |
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Miner’s Degree of Cooperation: Good Fair Poor Miner’s ability to understand instructions Good Fair Poor and follow directions: |
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(b) Observed values BEFORE Bronchodilator (Corrected to BTPS) Be sure to also note your findings in Block D5 of the CM-988, if applicable. |
(c) Observed values AFTER Bronchodilator, if given (Corrected to BTPS) Be sure to also note your findings in Block D5 of the CM-988, if applicable. |
(d) Predicted Normal Values |
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FEV1 (In liters/second) (Required)
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FVC (In liters) (Required)
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FEV1/FVC Ratio (Required)
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MVV (In liters / minute) (Optional)
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If the miner was unable to complete the test, explain the reason for such failure.):
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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 $1000, or imprisonment for up to one year, or both.
____________________________________ ____________________________________ _____________________ Print or Type Name of Physician Physician’s Signature Date
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NOTE: Persons are not required to respond to this collection of information unless it displays a current valid OMB control number.
CM-2907 (Rev. 05-11)
File Type | application/msword |
File Title | Report of Ventilatory Study |
Author | Michael McClaran |
Last Modified By | yferguso |
File Modified | 2011-08-24 |
File Created | 2011-05-24 |