CM-1159 Report of Arterial Blood Gas Test

Report of Arterial Blood Gas Study
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U.S. Department of Labor

Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

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OMB No. 1240-0023
Expires: XX-XX-XXXX

This report is authorized by law (30 USC 901 et. seq). The results of this study will aid in determining the miner's eligibility for
black lung benefits. This method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974,
and OMB Circular No. 108.

Instructions: Summarized below are the procedures to be followed in administering this test. The arterial blood gas study shall initially be administered at
rest and in a sitting position. If the results of the test at rest are not within the values indicated on the applicable table shown on the reverse side of
this form, an exercise blood gas study shall be offered to the miner unless medically contraindicated. *If an exercise blood gas test is
administered, blood shall be drawn during exercise. Complete instructions for administration of this test and table of values may be found in 20 CFR Part
718, Subpart B, 718.105, and appendix C.

2. DOL's Case ID Number

1. Name of Miner (First, middle, last)
4. Miner's:

5. Altitude: (Check one)
Age

3. Date of Test (mm/dd/yyyy)

6. Barometric Pressure

0 to 2999 feet above sea level
(Equipment Temperature)

3000 to 5999 feet above sea level

Height (inches and in
stocking feet – no shoes)
Weight (lbs.)

0

6000 feet or more above sea level

7. Site of Puncture:

C

Indwelling line:

Single stick:

8. Miner’s last date of acute respiratory or cardiac illness (mm/dd/yyyy):
a.

Iced

Time Sample
Drawn

Yes

No

b. Miner's pulse rate at time sample drawn:

Time Sample
Analyzed

During

*Exercise

Rest:

*

Rest:

c. Was equipment calibrated before and after each test?

During Exercise:*

Yes

No

d. Type of exercise and duration:*

9.
Observed Values
Test Results

Predicted Normal Range

Resting

Exercise if Administered*

pCO2(mmHg)
PO2 (mmHg)

pH

*Is the exercise portion of this study medically contraindicated? If YES,
for what reason?

Yes

No

10. Additional
Comments:
11 a. Facility where test performed:

12. Print or type name of technician performing the study:

11 b. Provider Number :

13. Print or type the name of physician supervising the test:

14. Physician's Signature: I certify that the information furnished is correct and am aware that my signature attests to the accuracy of the
results reported. I am also aware that any person who willfully makes any false or misleading statement or representation in support of
an application for benefits shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, subject to a fine of up to $1000, or
imprisonment for up to one year, or both.
Signature:

Date:
CM-1159
Revised MMYYYY

Blood Gas Tables
The following tables set forth the values to be applied in determining whether total disability may be
established in accordance with the criteria contained in 20 CFR 718.
(1) For arterial blood gas studies performed at test sites up
to 2,999 feet above sea level:

(2) For arterial blood gas studies performed at test sites
3,000 to 5,999 feet above sea level:

Arterial pO2
equal to or
less than (mmHg)

Arterial pCO2 (mmHg)

25 or below
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40-49
50 and Above -----------------------------

Arterial pCO2 (mmHg)

Arterial pO2
equal to or
less than (mmHg)

25 or below
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40-49
50 and Above -----------------------------

75
74
73
72
71
70
69
68
67
66
65
64
63
62
61
60
(1)

1

70
69
68
67
66
65
64
63
62
61
60
59
58
57
56
55
(2)

2

Any value

Any value
(3) For arterial blood gas studies performed at test sites
6,000 feet or more above sea level:
Arterial pO2
equal to or
less than (mmHg)

Arterial pCO2 (mmHg)

65
64
63
62
61
60
59
58
57
56
55
54
53
52
51
50
(3)

25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40-49
50 and Above
3

Any value
Public Burden Statement
We estimate that it will take an average of 15 minutes to complete this information collection including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you
have any comments regarding this burden estimate or any other aspect of this information collection, including suggestions for
reducing this burden, send them to the Division of Coal Mine Workers' Compensation, U.S. Department of Labor, Room N-3464, 200
Constitution Avenue, NW, Washington, DC. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

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CM-1159
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PRIVACY ACT NOTICE
The following information is provided in accordance with the Privacy Act of 1974, 5 USC 552a. (1) Submission of this information is
required under the Black Lung Benefits Act. (2) The information will be used to determine eligibility for and the amount of benefits
payable under the Act. (3) The information may be used by other agencies or persons in handling matters relating, directly or
indirectly, to the subject matter of the claim, including potentially liable coal mine operators and their insurance carriers; medical
professionals in obtaining medical services or evaluations; contractors providing automated data processing services to the
Department of Labor; representatives of the parties to the claim; and federal, state or local agencies in obtaining information about
eligibility for benefits.. (4) Furnishing all requested information will facilitate the claims adjudication process; and the effects of not
providing all or any part of the requested information may delay the process, or result in an unfavorable decision or a reduced level of
benefits. (5) This information is included in a System of Records, DOL/OWCP-2, published at 81 Federal Register 25765, 25858
(April 29, 2016), or as updated and republished.
NOTICE
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive
help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims process. For
example, we will provide you with copies of documents in alternate formats, communication services such as sign language
interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or the
claims examiner to ask about this assistance.
Note: Persons are not required to complete this collection of information unless it displays a currently valid OMB control number.

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CM-1159
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