Report of Arterial Blood Gas Study Reset U.S. Department of Labor 2IILFH RI :RUNHUV &RPSHQVDWLRQ 3URJUDPV 'LYLVLRQ RI &RDO 0LQH :RUNHUV &RPSHQVDWLRQ Print OMB No.  Expires:  This report is authorized by law (30 USC 901 et. seq) and required to obtain a benefit. The results of this interpretation will aid in determining the miner's eligibility for black lung benefits. Disclosure of a social security number is voluntary. The failure to disclose such number will not result in the denial of any right, benefits, or privilege to which the claimant may be entitled. This method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974, and OMB Cir. No. 108. 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. 1. Name of Miner (First, middle, last) 4. Miner's: 2. SSN or DOL Claim No. 5. Altitude: (Check one) 3. Date of Test (mm/dd/yyyy) 6. Barometric Pressure Age 0 to 2999 feet above sea level Height 3000 to 5999 feet above sea level Weight 6000 feet or more above sea level (Equipment Temperature) C 0 7. Indwelling line: Site of Puncture: Iced Time Sample Drawn 8a. Yes No Time Sample Analyzed Single stick: b. Pulse rate at time sample drawn: Exercise * Rest: Rest: c. Was equipment calibrated before and after each test? Exercise:* Yes No d. Type of exercise and duration:* 9. 2EVHUYHG 9DOXHV %H VXUH WR DOVR DQQRWDWH \RXU ILQGLQJV LQ %ORFN ' RI WKH &0 LI DSSOLFDEOH Test Results Predicted Normal Range Resting Exercise it Administered* S&2PP+J PO2 (mmHg) pH *Is the exercise portion of this study medically contraindicated? If YES, for what reason? Yes No 10. Additional Comments: 11 a. Facility where test performed: 12. Print or type name of technician performing the study: 11 b. Provider Number : 13. Print or type the name of Physician: 14. Physician's Signature: , FHUWLI\ WKDW WKH LQIRUPDWLRQ IXUQLVKHG LV FRUUHFW DQG DP DZDUH WKDW P\ VLJQDWXUH DWWHVWV WR WKH DFFXUDF\ RI WKH UHVXOWV UHSRUWHG , DP DOVR DZDUH WKDW DQ\ SHUVRQ ZKR ZLOOIXOO\ PDNHV DQ\ IDOVH RU PLVOHDGLQJ VWDWHPHQWV RU UHSUHVHQWDWLRQV LQ VXSSRUW RI DQ DSSOLFDWLRQ IRU EHQHILWV VKDOO EH JXLOW\ XQGHU  86&  RI D PLVGHPHDQRU DQG VXEMHFW WR D ILQH RI XS WR  RU LPSULVRQPHQW IRU XS WR RQH \HDU RU ERWK Signature: Date: CM-1159 5HY  American LegalNet, Inc. www.FormsWorkFlow.com 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: Arterial P02 equal to or less than (mmHg) Arterial pCO2 (mmHg) 25 or below 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40-49 Above 50 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 (1) (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) 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 (2) 25 or below 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40-49 Above 50 50 and Above 50 and Above 1 2 Any value Any value (3) For arterial blood gas studies performed at test sites 6,000 feet or more above sea level: Arterial pCO2 (mmHg) Arterial P22 equal to or less than (mmHg) 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 (3) 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40-49 Above 50 50 and Above 3 Any 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 these estimates or any other aspect of this survey, 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. Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. American LegalNet, Inc. www.FormsWorkFlow.com &0 3$*(  5HY