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SECTION/MEASURE
FORMAT
DEMOGRAPHICS
1
2
3
4
5
6
Client ID
Site ID
Last Name
First Name
Date of Birth
Last 4 SSN
7
Sex
8
Miner's age, in years, at the end of project period (June 30)
9
Race
10 Ethnicity
11 State of miner's residence at the end of project period
Auto-generate
numeric text field
Text field
Text field
MM/DD/YYYY or MM-DD-YYY
Text field
1= Male
2=Female
0=Other, Unreported, Chose not to disclose
numeric text field
1=American Indian/Alaska Native
2=Asian; Black/African American
3=Native Hawaiian
4=Other Pacific Islander
5=White
6=More than one race
0=Unreported/Refused to report race
1=Hispanic/Latino
2=Non-Hispanic/Latino
0=Unreported/Refused to report ethnicity
01=Alabama
02=Alaska
04=Arizona
05=Arkansas
06=California
08=Colorado
09=Connecticut
10=Delaware
11=District of Columbia
12=Florida
13=Georgia
15=Hawaii
16=Idaho
17=Illinois
18=Indiana
19=Iowa
12 Insurance Status at the end of project period
VISIT INFORMATION
13 Date of encounter
20=Kansas
21=Kentucky
22=Louisiana
23=Maine
24=Maryland
25=Massachusetts
26=Michigan
27=Minnesota
28=Mississippi
29=Missouri
30=Montana
31=Nebraska
32=Nevada
33=New Hampshire
34=New Jersey
35=New Mexico
36=New York
37=North Carolina
38=North Dakota
39=Ohio
40=Oklahoma
41=Oregon
42=Pennsylvania
44=Rhode Island
45=South Carolina
46=South Dakota
47=Tennessee
48=Texas
49=Utah
50=Vermont
51=Virginia
53=Washington (state)
54=West Virginia
55=Wisconsin
56=Wyoming
1=Insured
2=Uninsured
MM/DD/YYYY or MM-DD-YYY
14 Clinic Name
15
Is the miner currently prescribed home oxygen, or is home oxygen
recommended as a result of the clinic evaluation?
16 Is this a federal DOL medical examination?
PULMONARY DIAGNOSES
17
Which of the following diagnoses, if any, is the miner's most recent
primary pulmonary diagnosis, as determined by a physician or provider?
18 If selected "Other Lung Disease," please list the disease
Apart from the primary pulmonary diagnosis, which of the following
19 pulmonary diagnoses, if any, has the miner ever been diagnosed with, as
determined by a physician or provider? Check all that apply.
20 If selected "Other Lung Disease," please list the disease
OTHER SELECTED DIAGNOSES
Numeric entry from clinic sites associated with the grantee
1=Currently prescribed home oxygen
2=Not currently prescribed home oxygen and not recommended as a result
of clinic evaluation
3=Not currently prescribed home oxygen, but recommended as a result of
clinic evaluation
1=Yes
2=No
0=No lung disease
1=Simple coal workers' pneumoconiosis
2=Complicated coal workers' pneumoconiosis/Progressive Massive Fibrosis
3=Chronic obstructive pulmonary disease (COPD)
99=Other lung disease
Text field
Check all that apply:
0=No other diagnoses
1=Simple coal workers' pneumoconiosis
2=Complicated coal workers' pneumoconiosis/Progressive Massive Fibrosis
4=Chronic obstructive pulmonary disease (COPD)
5=Mixed dust pneumoconiosis
20=Silicosis
31=Lung cancer
32=Lung infection
99=Other lung disease
Text field
21 Miner's height (inches), without shoes
Numeric text field
22 Miner's weight (pounds)
Numeric text field
23 Miner's BMI
24 Systolic blood pressure
25 Diastolic blood pressure
Numeric text field
Numeric text field
Numeric text field
26 Has a physician or provider ever diagnosed the miner with hypertension?
1=Yes
2=No
Has a physician or provider ever diagnosed the miner with diabetes
mellitus?
1=Yes
2=No
27
Has a physician or provider ever diagnosed the miner with any of the
28
following types of malignancies?
1=Malignant Respiratory disease
2=Malignant Gastrointestinal Disease
3=Other Malignancy
4=No Diagnosed Malignancies
29 If selected "Other malignancy," enter malignancy here
Text field
SMOKING HISTORY
30 Did you conduct a smoking history assessment during this project year?
1=Yes
2=No
31 What was the date of the smoking history assessment?
MM/DD/YYYY or MM-DD-YYYY
32 What is the miner's current smoking status?
1=Never Smoked
2=Former Smoker
3=Currently Smoking
4=Unknown
33
On average, for the entire time the miner smoked, about how many
packs did/does the miner smoke per day? (1 pack = 20 cigarettes)
About how old was the miner when they first started smoking cigarettes
regularly?
About how old was the miner when they completely stopped smoking?
35
(if applicable)
34
36
During the time the miner was a smoker, did they ever stop smoking for
6 months or more?
37 How long did the miner stop smoking altogether? (years)
38
If miner is a current smoker, was smoke and tobacco cessation
counseling provided?
WORK HISTORY
Numeric text field
Numeric text field
Numeric text field
1=Yes
2=No
Numeric text field
1=Yes
2=No
39 Did you conduct a work history assessment during this encounter?
1=Yes
2=No
40 What was the date of the work history assessment?
MM/DD/YYYY or MM-DD-YYYY
41 Coal mining employment status
1=Active Coal Miner
2=Retired Coal Miner
3=Disabled Coal Miner
4=Retired and Disabled Coal Miner
5=Inactive Coal Miner--Currently Unemployed
6=Inactive Coal Miner--Currently Employed
42
What type of mining employment has the miner ever worked? (select all
that apply)
1=Underground coal
2=Surface Coal
3=Other mining types (metal or non-metal)
43 First year worked in underground coal mining
Numeric text field
44 First year worked in surface coal mining
Numeric text field
45 Last year worked in coal mining, if not active
Numeric text field
46
How many cumulative years did/has the miner worked in underground
coal mining, to date?
How many cumulative years did/has the miner worked in surface coal
mining, to date?
How many cumulative years did/has the miner worked in other mine
48
types (metal and non-metal), to date?
PULMONARY FUNCTION TEST
47
49 Did you conduct pulmonary function testing during this encounter?
50
If you conducted a Pulmonary Function Test during this project period,
what was the date?
Numeric text field
Numeric text field
Numeric text field
1=Yes
2=No
MM/DD/YYYY or MM-DD-YYYY
51 Pre-bronchodilator FVC (liters)
Numeric text field
52 Pre-bronchodilator FEV1 (liters)
Numeric text field
53 Post-bronchodilator FVC (liters)
Numeric text field
54 Post-bronchodilator FEV1 (liters)
Numeric text field
CHEST IMAGING
55 Did you conduct a Chest x-ray during this encounter?
56
If you conducted a Chest x-ray during this project period, what was the
date?
1=Yes
2=No
MM/DD/YYYY or MM-DD-YYYY
57 Was a B-Reading done on this x-ray?
1=Yes
2=No
58 Date B-read performed?
MM/DD/YYYY or MM-DD-YYYY
59 Image Quality
1=1
2=2
3=3
4=UR
60 Classifiable parenchymal abnormalities consistent with pneumoconiosis?
61 Primary small opacity shape/size
62 Secondary small opacity shape/size
63 Lung zones with small opacities
64 Profusion of small opacities
65 Large opacity size
1=Yes
2=No
1=p
2=q
3=r
4=s
5=t
6=u
1=p
2=q
3=r
4=s
5=t
6=u
1=Upper Right
2=Upper Left
3=Middle Right
4=Middle Left
5=Lower Right
6=Lower Left
1=0/2=0/0
3=0/1
4=1/0
5=1/1
6=1/2
7=2/1
8=2/2
9=2/3
10=3/2
11=3/3
12=3/+
1=O
2=A
3=B
4=C
66 Classifiable pleural abnormalities?
1=Yes
2=No
ARTERIAL BLOOD GAS
67 Did you conduct Arterial Blood Gas testing during this encounter?
68
If you conducted an Arterial Blood Gas Test during this project period,
what was the date?
1=Yes
2=No
MM/DD/YYYY or MM-DD-YYYY
69 Resting arterial pH
Text field
70 Resting arterial PCO2 (mmHg)
Text field
71 Resting arterial PO2 (mmHg)
Text field
72 Was exercise arterial testing also performed?
1=Yes
2=No
73 Exercise arterial pH
Text field
74 Exercise arterial PCO2 (mmHg)
Text field
75 Exercise arterial PO2 (mmHg)
Text field
76 Barometric pressure on date of test, if known
Text field
OTHER CLINICAL SERVICES
77
Did you refer the miner to any of the following providers during this
encounter? Select all that apply
78 If selected "Other" please list those here
79
Was an influenza vaccine administered during this clinic visit? Select only
one.
1=Pulmonologist
2=Primary Care Provider
3=Mental/Behavioral Health Care Provider
4=Nutritionist
5=Audiologist
6=Other
7=No referral made during this encounter
Text field
1=Not indicated/not influenza season
2=Vaccination administered
3=Previously vaccinated this season
4=Vaccination indicated, patient decline
5=Vaccination indicated, not offered to patient
80
81
Was a pneumococcal vaccine administered during this clinic visit? Select
only one.
1=Not indicated, previously vaccinated
2=Vaccination administered
3=Vaccination indicated, patient declined
4=Vaccination indicated, not offered to patient
5=Not indicated, not previously vaccinated
Was pulmonary rehabilitation provided onsite or through contract or
referral during this visit? Select only one.
1=Accredited phase II-onsite
2=accredited phase III-onsite
3=Accredited phase II-contract or referral
4=Accredited phase III-contract or referral
5=Basic information/education provided
6=Pulmonary rehabilitation not indicated
7=Pulmonary rehabilitation indicated, declined by patient
8=Pulmonary rehabilitation indicated, not offered
BENEFITS COUNSELING
82 Did you conduct benefits counseling services during this encounter?
83
84
1=State Workers' Compensation
2= Department of Labor
3=No
What was the date you assisted the miner in the filing of a state workers'
compensation claim during this project period?
MM/DD/YYYY or MM-DD-YYYY
If you assisted the miner in the filing of a workers' compensation claim
during this project period, in what state was it filed?
01=Alabama
02=Alaska
04=Arizona
05=Arkansas
06=California
08=Colorado
09=Connecticut
10=Delaware
11=District of Columbia
12=Florida
13=Georgia
15=Hawaii
16=Idaho
17=Illinois
18=Indiana
19=Iowa
20=Kansas
21=Kentucky
22=Louisiana
23=Maine
24=Maryland
25=Massachusetts
26=Michigan
27=Minnesota
28=Mississippi
29=Missouri
30=Montana
31=Nebraska
32=Nevada
33=New Hampshire
34=New Jersey
35=New Mexico
36=New York
37=North Carolina
38=North Dakota
39=Ohio
40=Oklahoma
41=Oregon
42=Pennsylvania
44=Rhode Island
45=South Carolina
46=South Dakota
47=Tennessee
48=Texas
49=Utah
50=Vermont
51=Virginia
53=Washington (state)
54=West Virginia
55=Wisconsin
56=Wyoming
85
What was the date you assisted the miner in the filing of a DOL Black
Lung Benefits claim during this project period?
MM/DD/YYYY or MM-DD-YYYY
86 What is the status of the DOL black lung benefits claim?
87
Date that you last checked the status of the miner's DOL black lung
benefits claim during this project period?
NIOSH SCREENING
Has the miner ever participated in the National Institute for
88 Occupational Safety and Health's Coal Workers' Health Surveillance
Program?
1=Interim award
2=ALJ award
3=DOL denial
4=DOL appeal
5=Claim withdrawn
6=Claim pending
7=Status unknown
MM/DD/YYYY or MM-DD-YYYY
1=Yes
2=No
3=Unsure
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |