Form 2.14 Spirometry Facility Certification

Attachment 15 – Spirometry Facility Certification Document – Form 2.14	Form Approved OMB No 0920-0020 Exp. Date xx/xx/20xx
SPIROMETRY FACILITY CERTIFICATION DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH	NIOSH Coal Workers' Health Surveillance Program 1095 Willowdale Road, M/S LB208 Morgantown, WV 26505 FAX: 304-285-6058

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
NIOSH Facility – Unit Number	_______________________________			_______________________________
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 treated in a secure manner and will not be disclosed, unless otherwise compelled by law.
_________________________________ Supervising Clinician (attach license copy)	____________________________ Email Address	__________________________ Signature	_______________ Date Signed
_______________________________________________ ___________________________________________ _______________ Clinician certification or specialized Title of course or certification Date Completed spirometry training Institution
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)
CDC/NIOSH 2.14 Rev. 01/2015