Form 1 BLCP PLD PIMS FY21_PY2021-2022

OMB #: 0915-0292
Expires: XX/XX/202X

Client ID

SECTION/MEASURE
DEMOGRAPHICS

Clinic Site ID
Last Name
First Name
Date of Birth
Last 4 SSN
Sex assigned at birth
Miner's age, in years, at the end of
project period (June 30)

Race

Ethnicity

FORMAT
Auto-generate from EMR/REDCap
Numeric entry from clinic sites associated with the
grantee
Text field
Text field
MM/DD/YYYY or MM-DD-YYY
Numeric text field
0=Other, Unreported, Chose not to disclose; 1=
Male; 2=Female; 3=Intersex
numeric text field
0=Unreported/Refused to report race;
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 ethnicity;
1=Hispanic/Latinx; 2=Non-Hispanic/Latinx

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;
State of miner's residence at the end
29=Missouri; 30=Montana; 31=Nebraska;
of project period (June 30)
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;
Miner's insurance Status at the end
of project period (June 30)
VISIT INFORMATION
Client ID
Clinic Site ID
Date of encounter

1=Insured; 2=Uninsured; 3=Unknown
Auto-generate from EMR/REDCap
Numeric entry from clinic sites associated with the
grantee
MM/DD/YYYY or MM-DD-YYY

Is this a federal DOL medical
examination?
Is this a Coal Workers’ Health
Surveillance Program (CWHSP)
screening?
Miner's height (inches), without
shoes
Was miner's height taken standing or
wingspan?
Miner's weight (pounds), without
shoes
Miner's BMI
Systolic blood pressure
Diastolic blood pressure

1=Yes; 2=No
1=Yes; 2=No
Numeric text field
1=Standing; 2=Wingspan
Numeric text field

Numeric text field
Numeric text field
Numeric text field
1=Currently prescribed home oxygen; 2=Not
Is the miner currently prescribed
currently prescribed home oxygen and not
home oxygen, or is home oxygen
recommended as a result of clinic evaluation;
recommended as a result of the clinic 3=Not currently prescribed home oxygen, but
evaluation?
recommended as a result of clinic evaluation;
4=Unknown
PULMONARY DIAGNOSES
Which of the following diagnoses, if
any, is the miner's most recent
primary pulmonary diagnosis, as
determined by a physician or
provider? Select only one.

0=No lung disease; 1=Simple Coal Workers'
Pneumoconiosis (CWP); 2=Complicated Coal
Workers' Pneumoconiosis/Progressive Massive
Fibrosis (PMF); 3= Dust-Related Diffuse Fibrosis
(DDF); 4=Chronic Obstructive Pulmonary Disease
(COPD); 99=Other lung disease

If selected "Other Lung Disease,"
please list the disease

Text field

0=No other diagnoses; 1=Simple Coal Workers'
In addition to the primary pulmonary Pneumoconiosis (CWP); 2=Complicated Coal
Workers' Pneumoconiosis/Progressive Massive
diagnosis, which of the following
pulmonary diagnoses, if any, has the Fibrosis (PMF); 3=Dust-Related Diffuse Fibrosis
miner ever been diagnosed with, as (DDF); 4=Chronic Obstructive Pulmonary Disease
(COPD); 5=Mixed Dust Pneumoconiosis;
determined by a physician or
20=Silicosis; 31=Lung cancer; 32=Lung infection;
provider? Select all that apply.
99=Other lung disease
If selected "Other Lung Disease,"
please list the disease
OTHER SELECTED DIAGNOSES
Has a physician or provider ever
diagnosed the miner with
hypertension?

Text field

1=Yes; 2=No; 3=Unknown

Has a physician or provider ever
diagnosed the miner with diabetes
mellitus?
Has a physician or provider ever
diagnosed the miner with any of the
following types of malignancies?
Select all that apply.

1=Yes; 2=No; 3=Unknown
1=Malignant Respiratory disease of lung or
bronchus; 2=Other Malignancy; 3=No Diagnosed
Malignancies; 4=Unknown

If selected "Other Malignancy," enter
Text field
malignancy here
SMOKING HISTORY
Did you conduct a smoking history
assessment during this encounter this 1=Yes; 2=No
project year?
What is the miner's current cigarette 1=Never Smoked Cigarettes; 2=Former Cigarette
smoking status?
Smoker; 3=Current Cigarette Smoker; 4=Unknown
On average, for the entire time the
miner smoked cigarettes, about how
many packs did/does the miner
Numeric text field
smoke per day? (1 pack = 20
cigarettes)
About how old was the miner when
they first started smoking cigarettes Numeric text field
regularly?
About how old was the miner when
they completely stopped smoking
Numeric text field
cigarettes?
During the time the miner was a
smoker, did they ever stop smoking
cigarettes for 6 months or more?

1=Yes; 2=No; 3=Unknown/Miner Cannot Recall

How long did the miner stop smoking
Numeric text field
cigarettes altogether? (years)
What is the miner's current inhaled
tobacco products use status?
What type of inhaled tobacco
products does/did the miner use?
Select all that apply.

1=Never Used Inhaled Tobacco Products;
2=Formerly Used Inhaled Tobacco Products;
3=Currently Uses Inhaled Tobacco Products;
4=Unknown
1=ENDS; 2=Cigars; 3=Little Cigars; 4=Cigarillos;
5=Pipe; 6=Hookah; 7=Clove cigarettes; 8=Other

If selected "Other" please list the
inhaled tobacco product
How often did/does the miner use
these other tobacco or nicotine
products?
For approximately how many total
years did the miner use other inhaled
tobacco products?
If miner is a current cigarette or
inhaled tobacco user, was smoking
and tobacco cessation counseling
provided during this encounter this
project year?
WORK HISTORY
Did you conduct a work history
assessment during this encounter this
project year?

Coal mining employment status

In what type of mining employment
has the miner ever worked? (select
all that apply)
First year worked in underground
coal mining
First year worked in surface coal
mining

Last year worked in coal mining

Text field

1=Daily; 2=Most Days; 3=Some Days; 4=Rarely

Numeric text field

1=Yes; 2=No

1=Yes; 2=No
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
1=Underground coal; 2=Surface Coal; 3=Other
mining types (metal or non-metal)
Numeric text field
Numeric text field

Numeric text field

How many cumulative years did/has
the miner worked in underground
Numeric text field
coal mining, to date?

How many cumulative years did/has
the miner worked in surface coal
Numeric text field
mining, to date?
How many cumulative years did/has
the miner worked in other mine
Numeric text field
types (metal and non-metal), to
date?

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;
In what state did the miner spend the 26=Michigan; 27=Minnesota; 28=Mississippi;
majority of their coal mining career, 29=Missouri; 30=Montana; 31=Nebraska;
32=Nevada; 33=New Hampshire; 34=New Jersey;
regardless of type (surface or
35=New Mexico; 36=New York; 37=North
underground)?
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;
99=Unknown/Miner Cannot Recall

PULMONARY FUNCTION TEST
Did you conduct a 6 Minute Walk
Test during this encounter this
project year?
Did you conduct pulmonary function
testing (PFT) during this encounter
this project year?
Pre-bronchodilator FVC (liters)
Pre-bronchodilator FEV1 (liters)
Post-bronchodilator FVC (liters)
Post-bronchodilator FEV1 (liters)
Did you conduct diffusing capacity of
the lungs for carbon monoxide
(DLCO) testing during this encounter
this project year?
What was the DLCO
(ml/min/mmHg)?

1=Yes; 2=No

1=Yes;2=No
Numeric text field
Numeric text field
Numeric text field
Numeric text field
1=Yes; 2=No

Numeric text field

Was the DLCO measurement
corrected for total hemoglobin
(THB)?

1=Yes; 2=No

Were lung volumes measured during
1=Yes; 2=No
this encounter this project year?
What was the total lung capacity
Numeric text field
(TLC) in litres (L)?
What was the residual volume (RV) in
Numeric text field
litres (L)?
What was the functional residual
capacity (FRC) in litres (L)?

Numeric text field

What method was used to measure
lung volumes?
CHEST IMAGING
Did the miner have a chest x-ray
(CXR) during this encounter this
project year?
Was a B-Read done on an x-ray
during this encounter this project
year?
Date B-read performed?
Image Quality
Classifiable parenchymal
abnormalities consistent with
pneumoconiosis?
Primary small opacity shape/size

1=Helium; 2=Nitrogen; 3=Body plethysmography;
4=Unknown

Secondary small opacity shape/size

0=No Entry; 1=p; 2=q; 3=r; 4=s; 5=t; 6=u

1=Yes;2=No

1=Yes;2=No
MM/DD/YYYY or MM-DD-YYYY
0=No Entry; 1=1; 2=2; 3=3; 4=UR
1=Yes;2=No
0=No Entry; 1=p; 2=q; 3=r; 4=s; 5=t; 6=u

Large opacity size

0=No Entry; 1=Upper Right; 2=Upper Left;
3=Middle Right; 4=Middle Left; 5=Lower Right;
6=Lower Left
0=No Entry; 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/+
0=No Entry; 1=O; 2=A; 3=B; 4=C

Classifiable pleural abnormalities?

0=No entry; 1=Yes;2=No;

Lung zones with small opacities.
Select all that apply.
Profusion of small opacities

ARTERIAL BLOOD GAS
Did you conduct resting Arterial
Blood Gas (ABG) testing during this
encounter this project year?

1=Yes;2=No

Was the resting Arterial Blood Gas
(ABG) test conducted during this
encounter this project year on room
air or oxygen?
What was the miner's oxygen flow
rate (in liters per minute) during the
resting Arterial Blood Gas (ABG) test
conducted during this encounter this
project year?
Resting arterial pH
Resting arterial PCO2 (mmHg)
Resting arterial PO2 (mmHg)
Did you conduct exercise Arterial
Blood Gas (ABG) testing during this
encounter this project year?
Was the exercise Arterial Blood Gas
(ABG) test conducted during this
encounter this project year on room
air or oxygen?

1=Room Air;2=Oxygen

Numeric text field

Numeric text field
Numeric text field
Numeric text field
1=Yes;2=No

1=Room Air;2=Oxygen

What was the miner's oxygen flow
rate (in liters per minute) during the
exercise Arterial Blood Gas (ABG) test Numeric text field
conducted during this encounter this
project year?
Exercise arterial pH
Exercise arterial PCO2 (mmHg)
Exercise arterial PO2 (mmHg)

Numeric text field
Numeric text field
Numeric text field

What was the barometric pressure (in
mmHg) during the Arterial Blood Gas
Numeric text field
(ABG) testing during this encounter
this project year, if known?
OTHER CLINICAL SERVICES

1=Pulmonologist; 2=Primary Care Provider;
Did you refer the miner to any of the 3=Mental/Behavioral Health Care Provider;
following providers or services during 4=Nutritionist; 5=Audiologist; 6=Computerized
this encounter this project year?
Tomography (CT) scan; 7=Cardiologist; 8=Lung
Select all that apply
Biopsy; 9=Other; 10=No referral made during this
encounter
If selected "Other" please list those
here

Text field

Was an influenza vaccine
administered during this encounter
this project year? Select only one.

1=Not indicated/not influenza season;
2=Vaccination administered; 3=Previously
vaccinated this season; 4=Vaccination indicated,
patient declined; 5=Vaccination indicated, not
offered to patient; 6=Unknown/miner cannot
recall

Was a pneumococcal vaccine
administered during this encounter
this project year? 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; 6=Unknown/miner
cannot recall

Was at least one SARS-CoV-2 (aka
COVID-19 aka Coronavirus) vaccine
dose or booster administered during
this encounter this project year?
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; 6=Unknown/miner
cannot recall

Which SARS-CoV-2 (aka COVID-19 aka
1=First shot initiation; 2=Second shot completion;
Coronavirus) vaccine dose did you
3=Single shot completion; 4=Booster
administer?

Were SARS-CoV-2 (aka COVID-19 aka
Coronavirus) vaccine information or 1=Yes; 2=No; 3=Previously provided
resources provided to the miner?

Was pulmonary rehabilitation
provided to the miner onsite or
through contract or referral during
this encounter this project year?
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
Did you conduct benefits counseling
services during this encounter this
project year? Select all that apply.

1=Yes, State Workers' Compensation; 2= Yes,
Department of Labor; 3=No

In what state was the miner's
workers' compensation claim filed
during this encounter this project
year?

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;

What is the status of the DOL black
lung benefits claim as of this
encounter this project year?
NIOSH SCREENING
Has the miner ever participated in
the National Institute for
Occupational Safety and Health's
(NIOSH) Coal Workers' Health
Surveillance Program (CWHSP)?

1=Claim pending; 2=Interim award; 3=Appeal;
4=Final award; 5=Denial; 6=Claim withdrawn;
7=Status unknown

1=Yes; 2=No; 3=Unknown

Public Burden Statement: This collection seeks to compile data that may be useful in the continued improvement of the Black Lung Clinics Program.
HRSA may also provide collected data to Congress in order to satisfy requirements imposed by the Government Performance and Results Act of 1993
(Pub. L. 103-62). 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. The OMB control number for this information collection is 0915-0292 and it is valid until XX/XX/202X. This
information collection is required to obtain, or retain, benefits under section 417C of the Public Health Service Act (42 U.S.C. 285a–9). Public reporting
burden for this collection of information is estimated to average 12 hours per response, including the time for reviewing instructions, searching
existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room
14N136B, Rockville, Maryland, 20857 or [email protected].