CM-1159 Report of Arterial Blood Gas Test

Report of Arterial Blood Gas Study
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U.S. Department of Labor

Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

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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, benefits, 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 Cir. No. 108.

OMB No. 1240-0023
Expires: XX/XX/XXXX

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)

4. Miner's:

2. SSN or DOL Claim No.

5. Altitude: (Check one)

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

6. Barometric Pressure

Age

0 to 2999 feet above sea level

Height

3000 to 5999 feet above sea level

Weight

6000 feet or more above sea level

(Equipment Temperature)

0

C

7.
Indwelling line:

Site of Puncture:

8a.

Iced

Time Sample
Drawn

Yes

No

Single stick:

b. Pulse rate at time sample drawn:

Time Sample
Analyzed

*Exercise

Rest:

*

Rest:

c. Was equipment calibrated before and after each test?

Exercise:*

Yes

No

d. Type of exercise and duration:*

Observed Values
Be sure to also annotate your findings in Block D5 of
the CM-988, if applicable.

9.

Test Results

Predicted Normal Range

Resting

Exercise if Administered*

pCO2(mmHg)
PO2 (mmHg)

pH

*Is the exercise portion of this study medically contraindicated? If YES,
for what reason?

Yes

No

10. Additional
Comments:
11 a. Facility where test performed:

12. Print or type name of technician performing the study:

11 b. Provider Number :

13. Print or type the name of 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 that any person who willfully makes any false or misleading statements or representations 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:
CM-1159 (Rev. 2014)

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:
Arterial P02
equal to or
less than (mmHg)

Arterial pCO2 (mmHg)

25 or below
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40-49
Above 50

75
74
73
72
71
70
69
68
67
66
65
64
63
62
61
60
(1)

(2) For arterial blood gas studies performed at test sites
3,000 to 5,999 feet above sea level:
Arterial pCO2 (mmHg)

70
69
68
67
66
65
64
63
62
61
60
59
58
57
56
55
(2)

25 or below
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40-49
Above 50

50 and Above

50 and Above

1

2

Any value

Arterial pO2
equal to or
less than (mmHg)

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)
65
64
63
62
61
60
59
58
57
56
55
54
53
52
51
50
(3)

25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40-49
Above 50
50 and Above
3

Any 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 respond to this collection of information unless it displays a currently valid OMB control number.
CM-1159 PAGE 2 (Rev. 2014)

Privacy Act Statement
The following statement is made in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a). This report is authorized by
law (30 USC 922 section 20 CFR 725.513). The information you furnish on this form may be routinely disclosed without your consent
to another person or Government agency for purposes such as (1) to comply with Federal laws requiring the release of information
from our records; or (2) to conduct research and audit activities needed to assure the continuing integrity and improvement of the U.S.
Department of Labor representative payee program. Other routine disclosures of this information are listed in the Federal Register,
which will be made available upon request.

Accommodation Statement
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive
help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims process. For
example, we will provide you with copies of documents in alternate formats, communication services such as sign language
interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or your
claims examiner to ask about this assistance.

CM-1159 Page 3 (Rev. 2014)