Form 2.16 Spriometry Notification

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