Spirometry

Name: ____________________________________________________

Form Approved

OMB No. 0920-0200

Expires 06/30/2014

GUIDELINES FOR SPIROMETRY IN THE ECWHSP MOBILE (08/2012)

Spirometry will NOT be performed under the following circumstances:

• Oxygen use (make note on Miner ID Card)

• Blood Pressure reading higher than 160/100

• Heart Rate reading higher than 110

• Failure to obtain a Blood Pressure reading

If the miner passes all of the above criteria, proceed to the following questions:

1) Have you had any surgeries in the last 90 days? _____ Yes ______ No

If no, proceed to #2

If yes, what type of surgery? ________________________________________________

For abdominal, hernia, chest, back, neck-type surgeries

< 90 days ago = No spirometry

For all other surgeries:

Are you released from the doctor’s care? _______Yes _______No

If yes = spirometry -- If no = no spirometry

2) Have you ever had any heart trouble? _____ Yes _____ No

If no, proceed to #3

If yes, what type of trouble? ________________________________________________

For former miners -- Yes = no spirometry

For working miners:

Have you had any heart issues in the last 6 months? _____Yes ____ No

No = spirometry

Yes = no spirometry

3) Have you ever had a stroke: ____Yes _____No

If no, proceed to #4

If yes,

For working miners - <3 months = no spirometry

>3 months = spirometry

For former miners – No spirometry regardless of time

Public reporting burden of this collection of information is estimated to average 20 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA, 30333, ATTN: PRA (0920-0020).

4) Have you ever been told by a doctor that you have an aneurysm in your head or stomach?

_____ Yes ______ No

Working and Former Miners

No = spirometry

Yes = no spirometry

5) Are you having any asthma or allergy symptoms today? _____ Yes _____ No