16.1 -USACEOH-Medical Surveillance Service Request Form.pdf
PDF 322 KB Posted
- Attached to
- NWW Medical Surveillance Services
- Solicitation number
- W912EF24Q0001
About this file
This document is a medical surveillance service request form used by the U.S. Army Corps of Engineers Walla Walla District. The form requests various medical examinations, bloodwork, urine analysis, diagnostic tests, and vaccinations for employees based on their job duties and potential exposures such as asbestos, lead, welding, and commercial driving. Examinations include comprehensive physicals, respiratory and cardiac evaluations, audiograms, vision screening, and chest x-rays. Blood and urine tests cover contaminants like arsenic, cadmium, chromium, and lead. Hepatitis B and tetanus vaccinations are also requested. The completed form and medical documentation must be sent to the District's occupational health nurse. It must be reviewed and approved by the medical surveillance officer, industrial hygienist, and contracting officer's representative before services are provided to the employee.
The related federal contract opportunity is solicitation number W912EF24Q0001 for medical surveillance services to be provided to the U.S. Army Corps of Engineers Engineering District in Walla Walla by the successful offeror. Services will include those listed on the medical surveillance request form.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| W912EF24Q0001 Amendment 0001.pdf | ||
| 16.4 - USACEOH-5875 CDL Medical Exam.pdf | ||
| Attachment 2 - Quantities for Price Evaluation.xlsx | XLSX spreadsheet | |
| 16.3 - USACEOH-OSHA Respiratory Questionnaire.pdf | ||
| Attachment 3 - SCA Wage Determinations.pdf | ||
| 16.2 - USACEOH-793-Medical Clearance.pdf | ||
| Attachment 1 - Medical Testing Capabilities Chart.xlsx | XLSX spreadsheet | |
| W912EF24Q0001.pdf |
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Text version
MEDICAL SURVEILLANCE SERVICE REQUEST FORM
U.S. ARMY CORPS OF ENGINEERS, WALLA WALLA DISTRICT
Name (Last, First, MI):
Operating Project / Office:
Date of Last Exam:
Reason for Exam:
Title, Series: PD: PHA:
Employee’s Position / Tasks / Exposures (PTE) (select all that apply)
Asbestos Worker Painter
Bloodborne Pathogens & Wastewater, Potential for Exposure Pesticide Applicator
Chromium (VI), Potential for Exposure Powerhouse Worker
Commercial Driver’s License (CDL) Respirator User
Crane Operator & Load Handling Equipment (LHE) Security Guard
Hazardous Waste Worker & Emergency Response U.S. Coast Guard License Holder
Lead (Pb), Potential for Exposure (Lead Abatement worker) Welder
Lock Operator Wastewater / Sewage Worker
PHYSICAL EXAMINATION Needed exams Date of last exam
CDL Physical Exam: DOT Certified CDL Examination
Comprehensive Physical Examination: Evaluation of the worker’s ability to climb ladders, walk on uneven surfaces, lift/carry 40 pounds, wear non breathable personal protective equipment, medical history (no uncontrolled diabetes, epilepsy, uncontrolled cardiovascular problems, uncontrolled high or low blood pressure, mental, emotional, or nervous conditions). Full set of vitals (BP, Pulse, RR, SP02, Temp).
Physical Exam review of cardiovascular system: Review medical history and perform a focused physical assessment of the Cardiac System. Auscultation of heart tones and includes EKG. Full set of vitals (BP, Pulse, RR, SP02, Temp).
Physical exam review of respiratory system: Review medical history and perform a focused physical assessment of the respiratory system, to include but not limited to auscultation, pulmonary function test or spirometry and review of OSHA Respiratory Questionnaire. Full set of vitals (BP, Pulse, RR, SP02, Temp).
Physical Exam for Welders: Review medical history, review OSHA respiratory questionnaire, (preform a focused assessment of dermatology, urinary, respiratory, and cardiology) look at body for dermatitis, skin ulceration or nasal septum perforation, assess teeth, gums renal, hematologic, gastrointestinal assessment, reproductive history, past Lead exposures both work/non-work, neurological review. Full set of vitals (BP, Pulse, RR, SP02, Temp). Smoking status, and history.
Prostate Palpation – for men over 40 if exposed to Cadmium (Welders)
Review of OSHA respiratory Questionnaire
Post exam consultation – review exam results with employee
BLOOD WORK
Arsenic, Whole Blood
PART 1 – EMPLOYEE INFORMATION
PART 2 - MEDICAL SURVEILLANCE SERVICES REQUESTED
1. To be completed by District Medical Surveillance Officer, District Industrial Hygienist, & Project Safety Specialist/Colleterial Duty Safety Officer.
2. Provide date examination test was last performed.
3. These services may be utilized when required by the examining physician to provide a final medical disposition.
Attachment # 17.1
Cadmium, Whole Blood
Cholinesterase, Red Blood Cell (RBC)
Cholinesterase, Plasma
Chromium, Plasma
Complete Blood Count (CBC) with Differential
Comprehensive Metabolic Panel (CMP)
Gamma-Glutamyl Transferase (GGT)
Hemoglobin (Hb) A1c
Lead, Whole Blood
Lipid Panel
Liver Function Test (LFT)
Manganese, Whole Blood
Peripheral Smear (Lead)
Pregnancy Test (Lead)
Zinc Protoporphyrin (ZPP)
URINE ANALYSIS
Arsenic, Urine
Beta-2, Microglobulin (β2-M), Urine
Cadmium, Urine
Chromium, Urine
Lead, Urine
Manganese, Urine
Sickle Cell Screening
Urinalysis with Microscopic
DIAGNOSTIC
12 Lead Electrocardiogram (EKG)
Audiogram
Chest X-Ray (B-Reading)
Chest X-Ray (PA & Lateral Views)
Chest X-Ray (PA View)
Pulmonary Function Test (Spirometry (FVC) (FEV (1.0)))
Vision Screen by Orthorater (Visual Acuity (Snellen), Color Vision (Ishihara), and Vision Fields (To include- Depth Perception)
VACCINATIONS
Hepatitis B Titer
Hepatitis B Vaccination
Hepatitis C Titer
Tdap Vaccination
PART 3 – SERVICE REQUEST REVIEW AND AUTHORIZATION
Please Send all Completed Medical Documentation to:
U.S. Army Corps of Engineers, Walla Walla District ATTN:
Hannah Boudreaux RN-BSN, Occupational Health Nurse 201 N. Third Ave.
Walla Walla, WA 99362
The Service Requests Have Been Reviewed By:
Operating Project or District Representative:
Medical Surveillance Officer (MSO)/Industrial Hygienist (IH):
The Service Requests Have Been Approved By:
Contracting Officer’s Representative (if different from MSO / IH):
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