Form 2.16 Spriometry Notification

National Coal Workers' Health Surveillance Program (CWHSP)

Attachment 15

Spirometry Facility Employee - Notification form 2.16

OMB: 0920-0020

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Attachment 15- Spirometry Notification Form









































Form Approved

OMB No. 0920-0020

Expires xx/xx/20xx

SPIROMETRY NOTIFICATION FORM

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

1095 WILLOWDALE ROAD; M/S LB208

MORGANTOWN, WV 26505

FAX: 304-285-6058

SPIROMETRY FACILITY NAME


_______________________________

FACILITY CERTIFICATION NUMBER


_______________________________

MINER’S NAME (LAST, FIRST, MIDDLE INITIAL)


_______________________________________________________

MEDICAL RECORD NUMBER


___________________________

MINER’S MAILING ADDRESS


______________________________________________________

CITY


_____________________________

STATE


________

ZIP CODE


_____________

PHONE NUMBER


(______) ______-________

DATE OF BIRTH (MM/DD/YYYY)


____/____/________

SPIROMETRY TEST DATE (MM/DD/YYYY)


_____/_____/________

MINER’S HEIGHT


___________ cm or inches (circle)


MSHA MINE OR CONTRACTOR ID NUMBER


_______________________________

MINER’S WEIGHT


___________ kg or pounds (circle)



Please check whether component was completed:

Yes

No

Component Completed

Respiratory Assessment Form

Spirometry Pre-Test Checklist

Height and Weight Measured (in stocking feet)

Spirometry Test


Please indicate when data was transmitted to NIOSH (MM/DD/YYYY):

FAX

Mail

Electronic

Component Transmitted

_____/_____/________

_____/_____/________

_____/_____/________

Spirometry Notification Form

_____/_____/________

_____/_____/________

_____/_____/________

Respiratory Assessment Form




_____/_____/________

Spirometry Results



Public reporting burden of this collection of information is estimated to average 10 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).


CDC/NIOSH 2.?16 Rev 06/2014

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