Form 2.14 Spirometry Facility Certification

National Coal Workers' Health Surveillance Program (CWHSP)

Attachment 15

Spirometry Facility Supervisor - Certification Document 2.14

OMB: 0920-0020

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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


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