Form 2.17 Spirometry Results

Attachment 16 - Spirometry Results Form

Form Approved

OMB No. 0920-0020

Expires xx/xx/20xx

SPIROMETRY RESULTS FORM DEPARTMENT OF HEALTH AND HUMAN SERVICES UNITED STATES PUBLIC HEALTH SERVICE CENTERS FOR DISEASE CONTROL AND PREVENTION NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH COAL WORKERS' HEALTH SURVEILLANCE PROGRAM			SPIROMETRY FACILITY NAME ____________________________________­­­­­­­__________________________________
			FACILITY CERTIFICATE NUMBER ____________________________________­­­­­­­_____________________________
			SPIROMETRY TECHNICIAN NUMBER ______________________________________________________________________
MINER’S NAME __________________,____________________ ______ (Last) (First) (MI)			MEDICAL RECORD NUMBER ____________________________________­­­­­­­_____________________________
DATE OF BIRTH _____/_____/________ (MM/DD/YYYY)	SEX  M F		SPIROMETRY TEST DATE _____/_____/________ (MM/DD/YYYY)
RACE (check one) Ethnicity  American Indian or Alaska Native  Hispanic or Latino  Asian  Non-Hispanic or Latino  Black or African American  White  Other			SPIROMETER CALIBRATION CHECK DATE _____/_____/________ (MM/DD/YYYY)
			TEST ROOM CONDITIONS Temp ___ C ___ F Barometric Press _____ mmHg
			TESTING POSITION  Standing  Seated
MINER’S HEIGHT (stocking feet) ______ cm or inches (circle)		MINER’S WEIGHT (stocking feet) ______ kg or pounds (circle)

SPIROMETRY TEST RESULTS *
	Trial # ___	Trial # ___	Trial # ___
FVC
FEV1
FEV6
Peak Expiratory Flow
Technician’s Evaluation of Miner’s Effort  Maximal  Sub-maximal  Uncertain

*Report results from 3 trials, which include the highest and second highest FVC and FEV1 values and the highest Peak Expiratory Flow value, from among all acceptable curves.

 Electronic copies of the volume-time and flow-volume curves for the trials above are included with this form.

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