Form 2.17 Spirometry Results

National Coal Workers' Health Surveillance Program (CWHSP)

Attachment 16

Spirometry Technician - Results Form 2.17

OMB: 0920-0020

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Attachment 16 - Spirometry Results Form




















































Form Approved

OMB No. 0920-0020

Expires xx/xx/20xx




SPIROMETRY RESULTS 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

SPIROMETRY FACILITY NAME


____________________________________­­­­­­­__________________________________

FACILITY CERTIFICATE NUMBER


____________________________________­­­­­­­_____________________________

SPIROMETRY TECHNICIAN NUMBER


______________________________________________________________________

MINER’S NAME __________________,____________________ ______

(Last) (First) (MI)

MEDICAL RECORD NUMBER


____________________________________­­­­­­­_____________________________



DATE OF BIRTH

_____/_____/________

(MM/DD/YYYY)

SEX

M F

SPIROMETRY TEST DATE

_____/_____/________

(MM/DD/YYYY)


RACE (check one) Ethnicity

American Indian or Alaska Native Hispanic or Latino

Asian Non-Hispanic or Latino

Black or African American

White

Other


SPIROMETER CALIBRATION CHECK DATE

_____/_____/________

(MM/DD/YYYY)

TEST ROOM CONDITIONS

Temp ___ C ___ F

Barometric Press _____ mmHg

TESTING POSITION

Standing Seated

MINER’S HEIGHT (stocking feet)

______ cm or inches (circle)

MINER’S WEIGHT (stocking feet)

______ kg or pounds (circle)



SPIROMETRY TEST RESULTS *


Trial # ___

Trial # ___

Trial # ___

FVC




FEV1




FEV6




Peak Expiratory Flow




Technician’s Evaluation of Miner’s Effort Maximal Sub-maximal Uncertain


*Report results from 3 trials, which include the highest and second highest FVC and FEV1 values and the highest Peak Expiratory Flow value, from among all acceptable curves.



Electronic copies of the volume-time and flow-volume curves for the trials above are included with this form.


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).


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