U.S. Department of Labor

Office of Workers' Compensation Programs 

Division of Coal Mine Workers' Compensation

Report of Arterial Blood Gas Study

OMB No. 1240-0023 

Expires: 11/30/2026

This report is authorized by law (30 USC 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.

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) 2. DOL's Case ID Number 3. Date of Test (mm/dd/yyyy)

4. Miner's: 5. Altitude: (Check one) 6. Barometric Pressure

Age 0 to 2999 feet above sea level

(Equipment Temperature) 3000 to 5999 feet above sea level 0

C

Weight (lbs.)

6000 feet or more above sea level

7. Site of Puncture: Indwelling line: Single stick:

a. Time Sample b. Miner's pulse rate at time sample drawn:

 Analyzed

 Iced

 Yes No

Time Sample

 Drawn

*Exercise

*

Rest:

Rest:

c. Was equipment calibrated before and after each test?

Yes No During Exercise:*

d. Type of exercise and duration:*

9. Observed Values 

Test Results Predicted Normal Range Resting Exercise if Administered*

pCO2(mmHg)

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 supervising the test:

14. Physician's Signature: I certify that the information furnished is correct and am aware that my signature attests to the accuracy of 

the results reported. I am also 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.

Signature: Date:

CM-1159

Revised April 2020

Height (inches and in

stocking feet – no shoes)

8. Miner’s last date of acute respiratory or cardiac illness (mm/dd/yyyy):

During

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: 

U.S. Department of Labor 

OWCP/DCMWC 

PO Box 8307 

London, KY 40742-8307 

For Further Information call TOLL FREE: 1-800-347-2502
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:

(2) For arterial blood gas studies performed at test sites 

3,000 to 5,999 feet above sea level:

Arterial pO2

equal to or

less than (mmHg)

Arterial pO2

equal to or

less than (mmHg)

Arterial pCO2 (mmHg) Arterial pCO2 (mmHg)

25 or below 75 25 or below 70

26 74 26 69

27 73 27 68

28 72 28 67

29 71 29 66

30 70 30 65

31 69 31 64

32 68 32 63

33 67 33 62

34 66 34 61

35 65 35 60

36 64 36 59

37 63 37 58

38 62 38 57

39 61 39 56

40-49 60 40-49 55

50 and Above (1) 50 and Above (2)

1

 Any value

2

 Any value

(3) For arterial blood gas studies performed at test sites 

6,000 feet or more above sea level:

Arterial pCO2 (mmHg) Arterial pO2

equal to or

less than (mmHg)

25 65

26 64

27 63

28 62

29 61

30 60

31 59

32 58

33 57

34 56

35 55

36 54

37 53

38 52

39 51

40-49 50

50 and Above (3)

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 this burden estimate or any other aspect of this information collection, 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 TO THIS OFFICE. 

CM-1159 PAGE 2 (Rev. April 2020)

----------------------------- -----------------------------
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.

CM-1159 PAGE 3 (Rev. April 2020)

Note: Persons are not required to complete this collection of information unless it displays a currently valid OMB control number.