Form 2.14 Facility Certification

Attachment 13- Spirometry Facility Certification Document

Form Approved

OMB No. 0920-0020

Expires xx/xx/20xx

Spirometry Facility Certification Document Form Approved OMB No. xxxx-xxxx CDC/NIOSH 2.?14 REV 06/2014

NIOSH Coal Workers' Health Surveillance Program 1095 Willowdale Rd. Morgantown, WV 26505

Facility Name Telephone Number

Street Address Email

^{City State} Zip Code ^County

^{Type of Facility (Mobile, Clinic, Private Office, Hospital)} How many spirometries per year? _________

Spirometry System(s) Used	Unit #1			Unit #2
Room Number (if applicable)	_______________________________			_______________________________
Manufacturer	_______________________________			_______________________________
Model	_______________________________			_______________________________
Serial #	_______________________________			_______________________________
Date acquired	_______________________________			_______________________________
Spirometer Validation Letter* (attached)	 Yes			 Yes
Automated Quality Control*	 Yes			 Yes
Calibration Check Available*	 Yes			 Yes
Graphical Displays
Meet 2005 ATS/ERS size standards*	 Volume-Time	 Flow-Volume		 Volume-Time	 Flow-Volume
Real-time during testing*	 Volume-Time	 Flow-Volume		 Volume-Time	 Flow-Volume
Test Report for Interpreter* (sample attached)	 Yes			 Yes
Spirometry data file
Stores 2005 ATS/ERS parameters*	 Yes			 Yes
Stores all maneuvers	 Yes	 if No, max # ___		 Yes	 if No, max # ___
Electronic Output Format*	 2005 ATS/ERS	 NIOSH-approved		 2005 ATS/ERS	 NIOSH-approved
*Items indicated by asterisk are required
Spirometry procedure manual available in laboratory  Yes (mo/yr revised_____/______)  No
Ongoing spirometry quality assurance program  Yes (mo/yr revised_____/______)  No
Height Measurement Device	 Stadiometer (brand) __			 Other
Weight Measurement Device	 Medical scale (brand)			 Other

Name(s) of Spirometry Technologist(s) Copy of NIOSH-Approved Spirometry Certificate attached

 Yes

 Yes

 Yes

 Yes

I agree to participate in this program in the manner specified by Part 37 of the Code of Federal Regulations (42 CFR Part 37), and understand that all information used in connection with this program will be held STRICTLY CONFIDENTIAL and divulged only as specified by the above Regulation.

Supervising Clinician (copy of license attached) Signature ^Date

Clinician certification or specialized spirometry training

Institution Title of course or certification Date completed

Public reporting burden of this collection of information is estimated to average 30 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).