Form 2.15 Spirometry Pre-test Checklist

Attachment 14- Spirometry Pre-test Checklist

Form Approved

OMB No. 0920-0020

Expires xx/xx/20xx

SPIROMETRY PRE-TEST CHECKLIST DEPARTMENT OF HEALTH AND HUMAN SERVICES UNITED STATES PUBLIC HEALTH SERVICE CENTERS FOR DISEASE CONTROL AND PREVENTION NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH COAL WORKERS' HEALTH SURVEILLANCE PROGRAM (CWHSP)
MINER’S NAME __________________,____________________ ______ (Last) (First) (MI)			MEDICAL RECORD NUMBER _____________________________________________________________________
DATE OF BIRTH _____/_____/________ (MM/DD/YYYY)			COMPLETION DATE _____/_____/________ (MM/DD/YYYY)
For items 1 – 6, review “Yes” responses with supervising clinician before testing.
Yes	No	1. Systolic BP >160; Diastolic BP >100; or Pulse rate is >110 beats per minutes. If yes, review with supervising clinician before testing.
Yes	No	2. Have you had any surgeries on your chest, abdomen, head, or eye (including Lasik) or had a heart attack or stroke in the last 6 weeks? If yes, consult supervising clinician before testing and consider reschedule after 6-8 weeks.
Yes	No	3. Have you had a cold, flu, or respiratory infection in your chest within the last 3 weeks? If yes and symptoms still persist, consider reschedule in 6 weeks.
Yes	No	4. Have you ever been told by a doctor that you have an aneurysm or a weakness in a major blood vessel? If yes, consult supervising clinician before testing.
Yes	No	5. Have you ever had a collapsed lung (pneumothorax)? If yes, consult supervising clinician before testing.
Yes	No	6. Have you coughed up any blood of unknown origin within the past 6 weeks? If yes, review with supervising clinician before testing.
Yes	No	7. Have you eaten a heavy meal within the last hour? If yes, try to wait 1 hour before testing.
Yes	No	8. Have you smoked within the last hour? If yes, try to wait 1 hour before testing.

Public reporting burden of this collection of information is estimated to average 5 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0020).