CM-1159 Report of Arterial Blood Gas Study

Report of Arterial Blood Gas Study 

U.S. Department of Labor Office of Workers’ Compensation Programs Division of Coal Mine Workers’ Compensation

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.

OMB No. 1240-0023 Expires: 12/31/2023

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.

Name of Miner (First, middle, last)

DOL’s Case ID Number

Date of Test (mm/dd/yyyy)

Miner’s: _______________ Age _______________ Height (inches and in stocking feet – no shoes) _______________ Weight (lbs.)

Altitude: (Check one)

Barometric Pressure ___________________________ Equipment Temperature __________________________ Cº

  

0 to 2999 feet above sea level 3000 to 5999 feet above sea level 6000 feet or more above sea level

7. Site of Puncture: ________________ Indwelling line: ________________ Single stick: _________________

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

a.

Time Sample Drawn

Iced Yes No

Time Sample Analyzed

Miner’s pulse rate at time sample drawn: During Rest: ____________ *Exercise: ___________ Was equipment calibrated before and after each test?  Yes  No

Rest:

 

During Exercise: *

 

d. Type of exercise and duration:*

9. Test Results

Predicted Normal Range

Observed Values

Resting

Exercise if Administered*

pCO2 (mmHg)

pO2 (mmHg)

pH

*Is the exercise portion of this study medically contraindicated?  Yes  No If YES, for what reason?

10. Additional Comments:

11 a. Facility where test performed: 11 b. Provider Number:

Print or type name of technician performing the study:

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:

TWO FILING OPTIONS:

1. To file electronically, submit completed form to the COAL Mine Portal: https://eclaimant.dol.gov/portal/?program_name=BL

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

U.S. Department of Labor

OWCP/DCMWC

PO Box 8307

London, KY 40742-8307

CM-1159 (Rev. April 2020)

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 pCO2 (mmHg) Arterial pO2 equal to or less than (mmHg)							Arterial pCO2 (mmHg) Arterial pO2 equal to or less than (mmHg)
25 or below					75		25 or below					70
26					74		26					69
27					73		27					68
28					72		28					67
29					71		29					66
30					70		30					65
31					69		31					64
32					68		32					63
33					67		33					62
34					66		34					61
35					65		35					60
36					64		36					59
37					63		37					58
38					62		38					57
39					61		39					56
40-49					60		40-49					55
50 and Above					(1)		50 and Above					(2)

¹ Any Value ² Any Value

(3) For arterial blood gas studies performed at test sites 6,000 feet or more above sea level:
Arterial pCO2 (mmHg) Arterial pO2 equal to or less than (mmHg)
25						65
26						64
27						63
28						62
29						61
30						60
31						59
32						58
33						57
34						56
35						55
36						54
37						53
38						52
39						51
40-49						50
50 and Above					(3)

³Any 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.

PRIVACY ACT NOTICE

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) the Black Lung Benefits Act (BLBA) (30 U.S.C. 901

et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives and

maintains personal information, relative to this application, on claimants and their immediate families; (2) information obtained by OWCP will be used to

determine eligibility for benefits payable under the BLBA; (3) information may be given to other government agencies, coal mine operators potentially liable for

payment of the claim or to the insurance carrier or other entity which secured the operator's compensation liability, contractors providing automated data processing services to the Department of Labor; and representatives of the parties to the claim; (4) information may be given to physicians or other medical service providers for use in providing treatment, making evaluations and for other purposes relating to the medical management of the claim; (5) information may be given to the Department of Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to render decisions with respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local agencies for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have been paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law; (7) disclosure of the claimant's or deceased miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary, and the SSN and/or TIN and other information maintained by the OWCP may be used for identification and for other purposes authorized by law; (8) failure to disclose all requested information, may delay the processing of this claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits; and (9) 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.

CM-1159 PAGE 2 (Rev. April 2020)