The Division of Coal Mine Workers' Compensation (DCMWC) uses this report for the arterial blood gas study in a coal miner's black lung benefits claim, part of the pulmonary evaluation alongside the exam, x-ray and ventilatory study. The test starts at rest with the miner seated; if resting values do not fall within the qualifying table for the site's altitude, an exercise study is offered unless medically contraindicated.
The testing facility completes the whole form and names the technician in item 12. The physician who supervised the test prints their name in item 13 and signs the accuracy certification in item 14.
Download the current version from the source each time; forms change without notice.
Report of Arterial Blood Gas Study
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Not always. The study starts at rest in a sitting position. Only if the resting results are not within the values on the applicable table must an exercise study be offered, unless it is medically contraindicated. When exercise is done, blood is drawn during exercise and the form records the exercise type and duration.
The physician supervising the test prints their name in item 13 and signs item 14, certifying the results are accurate. The technician who performed the study is named separately in item 12, and the facility and its provider number go in item 11.
Page 2 has three tables, one for each altitude band, listing for each pCO2 level the pO2 value at or below which total disability may be established under 20 CFR 718. The pO2 thresholds are lower at higher test sites, so the altitude band and barometric pressure must be recorded.