CM-2907 Report of Ventilatory Study

Report of Ventilatory Study ^{U.S. Department of Labor}

Office of Workers’ Compensation Programs

Division of Coal Mine Workers’ Compensation

Note: This report is authorized by law (30 U.S.C. 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.

OMB No. 1240-0023

Expires XX/XX/XXXX

Instructions: Any ventilatory study conducted after January 19, 2001 must include tracings of flow versus volume (flow-volume loop) as part of the reported test. If the spirometer used for this test cannot provide a flow-volume loop, indicate this fact in item 10. Submit three tracings of the flow-volume loop which displays the entire maximum inspiration and the entire maximum forced expiration, and three tracings of the volume versus time (spirogram) derived electronically from the flow-volume loop. Identify each tracing with the patient's name and DOL’s Case ID Number. Report the results of the FEV1, the FVC and the FEV1/FVC ratio (expressed as a percentage). If a bronchodilator is administered, report the values obtained both before and after bronchodilation and explain the significance of the results obtained in item 10. Measuring and reporting the MVV is optional. If the MVV is measured, submit two tracings of the individual breath volumes versus time if the MVV values obtained are within 10% of each other; otherwise, submit three tracings. The MVV results must be obtained independently, rather than calculated from the FEV1. Complete instructions and standards for administration of these tests may be found in 20 CFR Part 718, Subpart B, 718.103, and Appendix B, and are summarized on Form CM-2954a

1. Name of Miner (First, middle, last)			2. DOL’s Case ID Number:		3. Date and Time of Test MM | DD | YYYY a.m. p.m.
4. Age:	5. Sex:		8. Circle as appropriate (If “poor”, explain in no. 10. “Additional Comments”, the nature and extent of any impact this factor had on the results obtained.) Miner’s Degree of Cooperation: Good Fair Poor Miner’s ability to understand instructions Good Fair Poor and follow directions:
6. Height (Inches): (Stocking Feet – No Shoes)	7. Weight (lbs.):
9. (a) Type of Test		(b) Observed values BEFORE Bronchodilator (Corrected to BTPS) Be sure to also note your findings in Block D5 of the CM-988, if applicable.		(c) Observed values AFTER Bronchodilator, if given (Corrected to BTPS) Be sure to also note your findings in Block D5 of the CM-988, if applicable.		(d) Predicted Normal Values
FEV1 (In liters/second) (Required)
FVC (In liters) (Required)
FEV1/FVC Ratio (Required)
MVV (In liters/minute) (Optional)

10. Additional Comments (For example - note any dyspnea, use of bronchodilators, or coughing during test: If the miner was unable to complete the test, explain the reason for such failure.):

10. (a) Type of machine used (Trade name) (b) Rate of paper speed (c) Temperature of Equipment

TWO FILING OPTIONS:

1. To file electronically, submit completed form to the COAL Mine Portal:

https://eclaimant.dol-esa.gov/bl

2. To file by mail, send completed form to:

US Department of Labor

OWCP/DCMWC

PO Box 33610

San Antonio, TX 78265

I certify that these ventilatory studies were conducted and reported in compliance with specifications and instructions provided by the Department of Labor. I also certify that

the information furnished is correct and I am aware that my signature attests to the accuracy of the results reported. I am 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.

Print or Type Name of Physician

Physician's Signature

Public Burden Statement

Date

We estimate that it will take an average of 10 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of information, 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, N. W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM THIS OFFICE

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; 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 Systems of Records DOL/OWCP-2, DOL/OWCP-9, published at 81 Federal Register 25765, 25858, 25866 (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 respond to this collection of information unless it displays a currently valid OMB control number.

CM-2907

Revised April 2020