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 12/31/2023

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

Name of Miner (First, middle, last)

DOL’s Case ID Number:

Date and Time of Test: _____________ _______________ MM DD YYYY a.m.  p.m. 

Age:

Sex:

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:

Height (Inches): (Stocking Feet – No Shoes)

Weight (lbs.):

(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)

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.):

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

Facility where test performed

Print or Type Name and Title of Technician or Physician administering test

TWO FILING OPTIONS: 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: US Department of Labor OWCP/DCMWC PO Box 8307 London, KY 40742-8307 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

Date CM-2907 Revised April 2020

Public Burden Statement 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 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. 901et 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 respond to this collection of information unless it displays a currently valid OMB control number.

CM-2907

Revised April 2020