Form 1 BLCP Measure Instrument

O MB Number: 0915-0292

Expiration date: XX/XX/202X

Black Lung Clinics Program Performance Measures

Public Burden Statement: This collection seeks to compile data that may be useful in the continued improvement of the Black Lung Clinics Program. 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 Sec. 427(a) of the Federal Mine Safety and Health Act of 1977, as amended (30 U.S.C. 937), 42 C.F.R. part 55a). Public reporting burden for this collection of information is estimated to average 3.75 hrs. 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 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov.  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

SECTION/MEASURE	FORMAT
DEMOGRAPHICS
Client ID	Auto-generate from EMR/REDCap
Clinic Site ID	Numeric entry from clinic sites associated with the grantee
Last Name	Text field
First Name	Text field
Date of Birth	MM/DD/YYYY or MM-DD-YYY
Last 4 SSN	Numeric text field
Sex assigned at birth	0=Other, Unreported, Chose not to disclose; 1= Male; 2=Female; 3=Intersex
Miner's age, in years, at the end of project period (June 30)	numeric text field
Race	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
Ethnicity	0=Unreported/Refused to report ethnicity; 1=Hispanic/Latinx; 2=Non-Hispanic/Latinx
State of miner's residence at the end of project period (June 30)	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;
Miner's insurance Status at the end of project period (June 30)	1=Insured; 2=Uninsured; 3=Unknown
VISIT INFORMATION
Client ID	Auto-generate from EMR/REDCap
Clinic Site ID	Numeric entry from clinic sites associated with the grantee
Date of encounter	MM/DD/YYYY or MM-DD-YYY

Is this a federal DOL medical examination?	1=Yes; 2=No
Is this a Coal Workers’ Health Surveillance Program (CWHSP) screening?	1=Yes; 2=No
Miner's height (inches), without shoes	Numeric text field
Was miner's height taken standing or wingspan?	1=Standing; 2=Wingspan
Miner's weight (pounds), without shoes	Numeric text field
Miner's BMI	Numeric text field
Systolic blood pressure	Numeric text field
Diastolic blood pressure	Numeric text field
Is the miner currently prescribed home oxygen, or is home oxygen recommended as a result of the clinic evaluation?	1=Currently prescribed home oxygen; 2=Not currently prescribed home oxygen and not recommended as a result of clinic evaluation; 3=Not currently prescribed home oxygen, but 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
In addition to the primary pulmonary diagnosis, which of the following pulmonary diagnoses, if any, has the miner ever been diagnosed with, as determined by a physician or provider? Select all that apply.	0=No other diagnoses; 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); 5=Mixed Dust Pneumoconiosis; 20=Silicosis; 31=Lung cancer; 32=Lung infection; 99=Other lung disease
If selected "Other Lung Disease," please list the disease	Text field
OTHER SELECTED DIAGNOSES
Has a physician or provider ever diagnosed the miner with hypertension?	1=Yes; 2=No; 3=Unknown

Has a physician or provider ever diagnosed the miner with diabetes mellitus?	1=Yes; 2=No; 3=Unknown
Has a physician or provider ever diagnosed the miner with any of the following types of malignancies? Select all that apply.	1=Malignant disease of lung or bronchus; 2=Other Malignancy; 3=No Diagnosed Malignancies; 4=Unknown
If selected "Other Malignancy," enter malignancy here	Text field
SMOKING HISTORY
Did you conduct a smoking history assessment during this encounter this project year?	1=Yes; 2=No
What is the miner's current cigarette smoking status?	1=Never Smoked Cigarettes; 2=Former Cigarette 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 smoke per day? (1 pack = 20 cigarettes)	Numeric text field
About how old was the miner when they first started smoking cigarettes regularly?	Numeric text field
About how old was the miner when they completely stopped smoking cigarettes?	Numeric text field
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 cigarettes altogether? (years)	Numeric text field
What is the miner's current inhaled tobacco products use status?	1=Never Used Inhaled Tobacco Products; 2=Formerly Used Inhaled Tobacco Products; 3=Currently Uses Inhaled Tobacco Products; 4=Unknown
What type of inhaled tobacco products does/did the miner use? Select all that apply.	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	Text field
How often did/does the miner use these other tobacco or nicotine products?	1=Daily; 2=Most Days; 3=Some Days; 4=Rarely
For approximately how many total years did the miner use other inhaled tobacco products?	Numeric text field
If miner is a current cigarette or inhaled tobacco user, was smoking and tobacco cessation counseling provided during this encounter this project year?	1=Yes; 2=No
WORK HISTORY
Did you conduct a work history assessment during this encounter this project year?	1=Yes; 2=No
Coal mining employment status	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
In what type of mining employment has the miner ever worked? (select all that apply)	1=Underground coal; 2=Surface Coal; 3=Other mining types (metal or non-metal)
First year worked in underground coal mining	Numeric text field
First year worked in surface coal mining	Numeric text field
Last year worked in coal mining	Numeric text field
How many cumulative years did/has the miner worked in underground coal mining, to date?	Numeric text field

How many cumulative years did/has the miner worked in surface coal mining, to date?	Numeric text field
How many cumulative years did/has the miner worked in other mine types (metal and non-metal), to date?	Numeric text field
In what state did the miner spend the majority of their coal mining career, regardless of type (surface or underground)?	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; 99=Unknown/Miner Cannot Recall
PULMONARY FUNCTION TEST
Did you conduct a 6 Minute Walk Test during this encounter this project year?	1=Yes; 2=No
Did you conduct pulmonary function testing (PFT) during this encounter this project year?	1=Yes;2=No
Pre-bronchodilator FVC (liters)	Numeric text field
Pre-bronchodilator FEV1 (liters)	Numeric text field
Post-bronchodilator FVC (liters)	Numeric text field
Post-bronchodilator FEV1 (liters)	Numeric text field
Did you conduct diffusing capacity of the lungs for carbon monoxide (DLCO) testing during this encounter this project year?	1=Yes; 2=No
What was the DLCO (ml/min/mmHg)?	Numeric text field

Was the DLCO measurement corrected for total hemoglobin (THB)?	1=Yes; 2=No
Were lung volumes measured during this encounter this project year?	1=Yes; 2=No
What was the total lung capacity (TLC) in litres (L)?	Numeric text field
What was the residual volume (RV) in litres (L)?	Numeric text field
What was the functional residual capacity (FRC) in litres (L)?	Numeric text field
What method was used to measure lung volumes?	1=Helium; 2=Nitrogen; 3=Body plethysmography; 4=Unknown
CHEST IMAGING
Did the miner have a chest x-ray (CXR) during this encounter this project year?	1=Yes;2=No
Was a B-Read done on an x-ray during this encounter this project year?	1=Yes;2=No
Date B-read performed?	MM/DD/YYYY or MM-DD-YYYY
Image Quality	0=No Entry; 1=1; 2=2; 3=3; 4=UR
Classifiable parenchymal abnormalities consistent with pneumoconiosis?	1=Yes;2=No
Primary small opacity shape/size	0=No Entry; 1=p; 2=q; 3=r; 4=s; 5=t; 6=u
Secondary small opacity shape/size	0=No Entry; 1=p; 2=q; 3=r; 4=s; 5=t; 6=u
Lung zones with small opacities. Select all that apply.	0=No Entry; 1=Upper Right; 2=Upper Left; 3=Middle Right; 4=Middle Left; 5=Lower Right; 6=Lower Left
Profusion of small opacities	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/+
Large opacity size	0=No Entry; 1=O; 2=A; 3=B; 4=C
Classifiable pleural abnormalities?	0=No entry; 1=Yes;2=No;
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?	1=Room Air;2=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?	Numeric text field
Resting arterial pH	Numeric text field
Resting arterial PCO2 (mmHg)	Numeric text field
Resting arterial PO2 (mmHg)	Numeric text field
Did you conduct exercise Arterial Blood Gas (ABG) testing during this encounter this project year?	1=Yes;2=No
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
What was the miner's oxygen flow rate (in liters per minute) during the exercise Arterial Blood Gas (ABG) test conducted during this encounter this project year?	Numeric text field
Exercise arterial pH	Numeric text field
Exercise arterial PCO2 (mmHg)	Numeric text field
Exercise arterial PO2 (mmHg)	Numeric text field
What was the barometric pressure (in mmHg) during the Arterial Blood Gas (ABG) testing during this encounter this project year, if known?	Numeric text field
OTHER CLINICAL SERVICES
Did you refer the miner to any of the following providers or services during this encounter this project year? Select all that apply	1=Pulmonologist; 2=Primary Care Provider; 3=Mental/Behavioral Health Care Provider; 4=Nutritionist; 5=Audiologist; 6=Computerized Tomography (CT) scan; 7=Cardiologist; 8=Lung 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 Coronavirus) vaccine dose did you administer?	1=First shot initiation; 2=Second shot completion; 3=Single shot completion; 4=Booster
Were SARS-CoV-2 (aka COVID-19 aka Coronavirus) vaccine information or resources provided to the miner?	1=Yes; 2=No; 3=Previously provided

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?	1=Claim pending; 2=Interim award; 3=Appeal; 4=Final award; 5=Denial; 6=Claim withdrawn; 7=Status unknown
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=Yes; 2=No; 3=Unknown