Report of Ventilatory Study

Report of Ventilatory Study                                  Print             Reset             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
                                                                                                                                                   OMB No. 1240-0023
black lung benefits. This method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974, and
                                                                                                                                                   Expires 11/30/2026
OMB Circular No. 108.
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
1. Name of Miner (First, middle, last)                2. DOL’s Case ID Number:                                      3. Date and Time of Test


                                                                                                                          MM | DD | YYYY                a.m.      p.m.
4. Age:                    5. Sex:                    8. 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.)

6. Height (Inches):        7. Weight (lbs.):              Miner’s Degree of Cooperation:                          Good           Fair        Poor
    (Stocking Feet –
    No Shoes)                                             Miner’s ability to understand instructions              Good           Fair        Poor
                                                          and follow directions:

                                                   (b) Observed values                         (c) Observed values
                                                  BEFORE Bronchodilator                       AFTER Bronchodilator,
                                                   (Corrected to BTPS)                    if given (Corrected to BTPS)
9. (a) Type of Test                               Be sure to also note your                  Be sure to also note your
                                                                                                                                     (d) Predicted Normal Values
                                                 findings in Block D5 of the                findings in Block D5 of the
                                                    CM-988, if applicable.                     CM-988, if applicable.
FEV1 (In liters/second) (Required)
FVC (In liters) (Required)
FEV1/FVC Ratio (Required)
MVV (In liters/minute) (Optional)
10. 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.):


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


12. Facility where test performed                                    13. Print or Type Name and Title of Technician or Physician administering test

TWO FILING OPTIONS:
      1. To file electronically, submit completed form to the COAL Mine Portal:
         https://coalmine.dol.gov

      2. To file by mail, send completed form to:
         US Department of Labor
         OWCP/DCMWC
         PO Box 8307
         London, KY 40742-8307
         For Further Information call TOLL FREE: 1-800-347-2502
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, 200 Constitution Avenue, N.W., Suite
C3520-DCMWC, 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. 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 respond to this collection of information unless it displays a currently valid OMB control number.




                                                                                                                                           Page 2
                                                                                                                                          CM-2907
                                                                                                                                 Revised April 2020