16.2 - USACEOH-793-Medical Clearance.pdf

USACE OH MED EXAM 793, FEB 2023 PREVIOUS EDITIONS ARE OBSOLETE VER 1.0

MEDICAL EXAMINATION CLEARANCE FORM (793)

1. NAME (Last, First, Middle Initial)

4. POSITION TITLE AND OCCUPATIONAL SERIES 5. LAST 4 OF SSN

2. DISTRICT

POST OFFER:

CRANEOPERATOR

(see attached crane requirements) US Coast Guard: CG719K

HAZMAT

(HAZWOPER Standard, 29 CFR 1910.120) Food Handler Respiratory Clearance

Welder Hearing Conservation Wildland Fire Management

CDL

FAA: Class ____

DIVER

Lock and Dam Operator

MEDICAL CLEARENCE (Do not include medical diagnoses on this form.)

RESPIRATOR CLEARENCE

TO BE COMPLETED BY THE EXAMINER/REVIEWER

FULL MEDICAL CLEARANCE

FOR THE FUNCTIONAL

REQUIREMENTS OF THIS

POSITION

CLEARANCE

DENIED

CLEARANCE

PENDING

ADDITIONAL

INFORMATION

RESULTS HAVE BEEN

REVIEWED WITH

EMPLOYEE

N/A EMPLOYEE/SELECTEE IS NOT ENROLLED IN RESPIRATORY PROTECTION PROGRAM

THIS EMPLOYEE HAS BEEN FOUND TO BE PHYSICALLY ABLE TO USE THE FOLLOWING (check each that applies):

Single use, filter mask (four attachment points)

Half-faced cartridge-type, negative pressure respirator, negative pressure

Half-faced powered cartridge-type (PAPR)

Full-faced powered cartridge-type (PAPR)

Self-contained breathing apparatus (SCBA) Full-faced cartridge-type

Hood/helmet powered cartridge-type (PAPR)

Half-faced/Full-faced/Hood/Helmet (NOT positive pressure)

1. EXAMINING PHYSICIAN NAME (Type or print in black ink)

1. EXAMINING PHYSICIAN/CLINIC ADDRESS (Type or print in black ink)

2. EXAMINING PHYSICIAN SIGNATURE

Signature Date

This employee has been found to be physically NOT able to use a respirator There is insufficient information to make a determination at this time.

The mandatory questionnaire has been reviewed, and the employee has been found to be physically able to use a respirator.

The mandatory questionnaire has been reviewed but there is insufficient information to make a determination at this time.

I attest that I have reviewed the position functional requirements, exposures, and history and physical.

This respirator clearance expires ______ years from the date below. (If not marked, clearance expires in one year).

Attachment 17.3