FD-899.pdf

FD-899

08/26/2025

FEDERAL BUREAU OF INVESTIGATION

FBI RESPIRATORY CLEARANCE AND HAZARDOUS

MATERIALS RESPONSE MEDICAL REPORT

Name: Age: Sex:

Employee ID#:

Title/Position: Name of Special Team:

Findings from questionnaire and targeted exam:

There is no significant evidence of disease or health impairment.

There is evidence of current disease or impairment that is:

Not etiologically related to and/or aggravated by employment

Possibly etiologically related to and/or aggravated by employment

Recommendations (Please check ALL that apply):

There are no physical restrictions that would prohibit the employee from safely operating in a physically strenuous and exertional environment with potentially elevated temperatures while wearing a constricting suit.

Employee is medically able to wear respirator.

Any type of respiratory equipment (including negative pressure respirators) may be used without restriction.

Restrictions and/or follow up are necessary (see below).

Employee was given a copy of this report and instructed to give employer/supervisor a copy.

Restrictions and/or follow up are necessary (comment below).

Comments

Physician or Nurse’s Signature: Date:

Privacy Act Statement: The collection of this information on this form, which is authorized by 5 U.S.C. § 301 and 5 U.S.C. § 3301, is relevant and necessary to provide appropriate medical care and to determine eligibility and/or fitness for duty. Completion of this form is voluntary; however, your failure to supply all the information requested on this form may impede or preclude agency action regarding medical care or continued employment. This information is maintained in your medical file in the FBI Central Records System, Justice/FBI-002, a description of which can be found at https://go.fbinet.fbi/DO/OGC/LTB/PCLU/Pages/PCLULibraryMenu.aspx.

This information maybe disclosed in accordance with the routine uses referenced in this notice.

GINA Notice: Do Not Provide Genetic Information, Including Family Medical History The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. See 29 C.F.R. § 1635.8(b)(1)(i)(B).

https://go.fbinet.fbi/DO/OGC/LTB/PCLU/Pages/PCLULibraryMenu.aspx

Title/Position: