Attachment_B_-_Forms_and_Documents.pdf

Version 1.0, February 2019 1

ATTACHMENT B:

cRMO Services

FORMS AND DOCUMENTS

Attachment B

Version 1.0, February 2019 2

Exam Checklist

**Please ensure that all paperwork is completed in full before returning to CHS with this checklist. **

Medical l History and Exam Paperwork EKG (50 years of age or older)

⌂ Page 1: Demographic Information

⌂ Date of Medical Exam Pulmonary Function Test/Spirometry ⌂ Name of Examinee (Only if history of asthma or other

⌂ Employer respiratory condition)

⌂ Date of Birth Labs

⌂ Sex ⌂ Chem Panel w/Lipids 304802

⌂ Last 4 of Social Security Number ⌂ CBC w/Diff/Platelet 005009

⌂ Email Address ⌂ ABO Group & Type 006049

⌂ Phone Number ⌂ RPR / Syphilis Screen 012005 ⌂ Page 2: Medical History ⌂ Hemoglobin A1c 001453

⌂ II. Medical history ⌂ HIV Screen 083935 ⌂ III. List of Current Medications ⌂ UA, Complete 003772

⌂ IV. Hospitalizations, Operations, Medical Evaluations ⌂ V. Signature of Examinee

⌂ G‐6‐PD 001917

⌂ Hepatitis panel 322744

⌂ Page 3: Clinical Evaluation Immunizations ⌂ Height ⌂ Hepatitis A

⌂ Weight 1st 2nd

⌂ BMI ⌂ Hepatitis B ⌂ Blood Pressure 1st 2nd 3rd

⌂ Repeat 3 times if >140/90 ⌂ Polio ‐ once as an adult ‐ ⌂ Page 4: Examiner Information ⌂ MMR ‐ Twice as an adult

⌂ Examiner Notes 1st 2nd

⌂ Examiner Name & Signature ⌂ Influenza ‐ ⌂ Date ⌂ Varicella ‐ Twice as an adult ⌂ Facility Name & Phone Number 1st 2nd

⌂ Td ‐ every 10 years ‐ Visual Screening/Snellen 20/40 ⌂ Tdap ‐ once ‐

⌂ Near & Distant ‐ Corrected ⌂ Typhoid ‐ every 2 years ‐ ⌂ Near & Distant ‐ Uncorrected ⌂ Yellow fever (only if from location with high risk of transmission) __________

Whisper Test (audiogram if failed whisper test) ⌂ RX Malaria, Not for IRAQ, Need for all others

PPD, Administration and Reading CHS HIPAA Authorization Form Administered Date

Read Date

Chest X‐Ray

CHS HIPAA Notice of Privacy Practice Form

Framingham score (ASCVD%)

(ONLY if +PPD or history of + PPD) Do you smoke? Yes

No

Version 1.0, February 2019 3

Instructions to Examining Healthcare Provider

Medical Guidelines

Examinees are responsible for maintaining good physical and mental health in such a way that they can safely perform their essential job functions, without accommodation.

Contractor employees are covered by the Rehabilitation Act of 1973. As such, an apparently disqualifying medical condition nevertheless requires that an individualized assessment be made to determine whether the examinee can perform the essential functions of their position in the deployed environment, with or without reasonable accommodation, without causing undue hardship. In evaluating undue hardship, the nature of the accommodation and the location of the deployment must be considered. Further, the Examinee's medical condition must not pose a substantial risk of significant harm to the Examinee or others when taking into account the conditions of the relevant deployed environment.

Deploying Examinees must have an evaluation by a medical provider to determine if they can safely deploy, considering the environmental and operational conditions of the deployed location.

Fitness for deployment to austere or hostile environments includes, but is not limited to, the ability to accomplish all required tasks and duties, by job requirements or duty position. At minimum, personnel must have the ability to run, jump, and evade, in the event of an imminent or ongoing threat or action and must be able to wear ballistic, respiratory, safety, chemical and biological personal protective equipment; use required prophylactic medications; and ingress/egress in emergency situations with minimal risk to themselves or others.

Immunizations

All immunizations will be administered based on the current CDC recommendations for travel to the country of deployment. Immunizations should be documented on the CDC – 731 Certificate of Vaccination or Prophylaxis (Yellow Shot Record).

Required Lab Tests:

G6PD Testing – Documentation of one‐time Glucose‐6‐Phosphate Dehydrogenase Deficiency Testing. Determines the ability of the employee to take Malaria Prophylaxis medication.

Tuberculosis (TB) Testing ‐ Reading should be performed within 48 ‐ 72 hours.

Chemistry Panel that includes Total Cholesterol, LDL, Triglycerides, Blood Sugar

(Glucose), Liver Function, Creatinine Complete Blood Count (CBC) with differential HIV Screen Syphilis Screen (RPR) Hepatitis panel Blood type, RH factor Urine Analysis – Complete Hemoglobin A1c

Version 1.0, February 2019 4

Instructions to Examining Healthcare Provider and Reviewing MD

Medical Clearance‐ Summary of the basic requirements, please refer to Attachment A for additional details

Weight < 300 lbs.

• BMI < 40

• Distant Vision 20/40 better eye – corrected

• Near Vision 20/40 better eye – corrected

• Hearing – Examinee must have sufficient unaided hearing to perform duties safely, hear and wake up to emergency alarms unaided, and hear instructions in the absence of visual cues, such as lip reading.

o Hearing Test – Whisper Test for all; audiogram if failed Whisper Test

• Blood Pressure – 140/90 or below

• ECG – to be performed on those 50 years of age or older OR if medically indicated

Framingham Score (Cardiac Risk Factor) – 14% or less

• CXR – this would be required if history of positive TB test OR if in certain foreign countries where it is required to do CXR instead of or in addition to TB Test.

• PFT – FEV 1 =/>50% ‐ This would be performed on anyone with history of asthma or other respiratory condition

• Obstructive Sleep Apnea (OSA) – moderate and severe OSA requires documentation of therapy over a 30‐day period prior to deployment.

• Lifting Capability o If deployment is in an austere / hostile location, must be able to lift 70 pounds o For all other locations there is not a specific lifting requirement

• Orthopedic – there should be no restrictions – normal ROM / ability to walk, sit, stoop, squat, raise arms above head.

o If deployment is an austere/hostile location, must be able to run to a bunker

• Diabetes o If deployment to hostile / austere environment – no insulin o HgbA1c < 7.0 is deployable

• Hernia o Inguinal Hernia – none o Umbilical – none, asymptomatic

• TB Test – negative via skin test or IGRA; negative chest x‐ray if positive TB screening test

Version 1.0, February 2019 5

Examining Healthcare Provider Statement Deployment Status

Examinee Name: Social Security Number:

Date of Birth: Date of Exam:

Opinion of Risk and Medical Clearance for Deployment

I have reviewed the Examinee's medical history and the results of the physical examination and laboratory test results. I certify that this individual has completed all the requirements for medical clearance.

Check all below that have been reviewed:

Medical History and Exam Paperwork Labs

⌂ Chem Panel w/Lipids

Psychological test, if indicated ⌂ CBC w/Diff/Platelet

⌂ ABO Group & Type

Visual Screening ⌂ RPR / Syphilis Screen

⌂ Hemoglobin A1c

Whisper test (audiogram if failed whisper test) ⌂ HIV Screen

⌂ UA, Complete

PPD, Administration and Reading ⌂ G‐6‐PD

Administered Date

Read Date

⌂ Hepatitis Panel

Chest X‐Ray All required immunizations administered for

ONLY if + PPD or history of + PPD location of deployment

EKG (50 years of age or older) Framingham Score (ASCVD%)

Pulmonary Function Test/Spirometry

ONLY if History of Asthma or Respiratory Condition

MEDICAL PROVIDER DEPLOYMENT DETERMINATION:

I have determined that this Examinee:

Meets recommended standards for the known job duties, including deployment to an overseas assignment

Does not meet recommended standards for the known job duties, including deployment to an overseas

Name of Medical Provider: Title of Medical Provider:

Signature of Medical Provider: Date of Review: ________________

Version 1.0, February 2019 6

Medical Examination and History

I. DEMOGRAPHIC INFORMATION

TO BE FILLED OUT BY EXAMINEE

DATE OF EXAM (mm-dd-yyyy)

1. Name of Examinee (Last, First, MI) 2. Employer

3. Date of Birth (mm-dd-yyyy) 4. Sex

Male Female

5. Place of Birth 6. Last Four Digits of Employee SSN

7. Email Address of examinee (Where you can be reached for the next 90 days)

8. Telephone number of examinee (Where you can be reached for the next 90 days)

To the individual and/or health care provider completing the medical history review /exam: 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 members' 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.

Version 1.0, February 2019 7

Name of Examinee DOB

II. MEDICAL HISTORY

PLEASE ANSWER THE FOLLOWING QUESTIONS: For YES answers, provide a brief explanation, attach additional sheets, if needed.

Do you have a history of:

Yes No

1. Frequent/severe headaches or migraines?

2. Fainting or dizzy episodes?

3. Stroke, TIA or head injury?

4. Epilepsy, seizures or other neurologic disorders?

5. Chronic eye or vision problems?

6. Ear, nose, throat problems; hearing loss, hoarseness?

7. Allergies or history of anaphylactic reaction?

8. Shortness of breath, asthma, or COPD?

9. History of abnormal chest x-ray?

10. History of positive TB skin test or tuberculosis?

11. Aneurysm, blood clot or pulmonary embolism?

12. High blood pressure?

13. Heart problems, murmur or palpitations?

14. Have you smoked in the last month?

15. Stomach, esophageal, intestinal problems?

16. Jaundice or hepatitis (type)?

17. Intestinal, rectal problems or hernia?

18. Urinary or kidney problems, blood in urine?

19. Diabetes or thyroid disorder?

20. Joint or back pain/injury?

Yes No

21. Rheumatologic disorder?

22. Anemia?

23. Blood transfusion?

24. Malaria or other tropical disease?

25. Any skin or nail disorder?

26. Cancer of any type?

27. Any thickening or lump in breast, testicle?

28. Sleep Apnea? If yes severity?_____________

Yes No

28. Have you consumed at any one time in the past year, more than 5 alcohol drinks for males or 4 drinks for females? Explain.

IN THE PAST SEVEN (7) YEARS (for questions 29-33)

29. Have you used marijuana, amphetamines, narcotics, cocaine, or hallucinogenic drugs?

30.Have you been in psychotherapy/counseling or been prescribed medication for depression, anxiety, mood or stress?

31. Have you felt unusually depressed, sad, blue, or had frequent crying spells which lasted more than two weeks at a time?

32. Have you had frequent or recurrent episodes of: anxiety, irritability, anger, hyperactivity, or nervousness?

33. Have you experienced any emotional or physical symptoms related to a past trauma?

Women: (provide results if applicable, N/A if not applicable)

34. Are you pregnant? Yes No

If yes, est. due date:

Men/Women: Colon Cancer Screening:

(provide results if applicable, N/A if not applicable)

35. Date of last colon cancer screening, if applicable:

Test (colonoscopy/sigmoidoscopy/guaiac/FOBT):

Results:

For all applicants, employees:

36. Is there any other medical or mental health condition not covered in questions 1 - 35? Yes No Explain:

IIA. Explanations required for "Yes" answers to questions 1-36. Attach additional sheets as needed.

III. LIST OF CURRENT MEDICATIONS (Include prescription, over the counter, vitamins, and herbs) Drug or Other Allergies

IV. HOSPITALIZATIONS/OPERATIONS/MEDICAL EVACUATIONS (Include all medical and psychiatric illnesses)

Date (mm-dd-yyyy) Illness or Operation Name of Hospital City and State

V. SIGNATURE OF EXAMINEE (I certify I have read and understand the above statement.)

Date (mm-dd-yyyy)

Version 1.0, February 2019 8

VI. INSTRUCTIONS FOR COMPLETION AND SUBMISSION

MEDICAL EXAMINER

• Medical Examiner must comment on positive history on page 2.

• Medical Examiner must comment on physical findings and provide recommendations for treatment/further study/consultations of medical & mental health problems.

• Medical Examiner must sign on page 4.

EXAMINEE

• Examinee must sign on page 2.

• Submit copies of all laboratory tests and additional medical reports

• All Lab tests and medical reports must be in English and identified with full name and date of birth of examinee.

VI: Medical Examiner comments on significant patient medical history and items checked "yes" on page 2/section II. Use additional pages, if needed.

VII: Clinical Evaluation:

1. Height

in. or cm.

2. Weight lbs. or kgs.

3. BMI 4. Pulse 5. Blood Pressure (sitting) If above 140/90 repeat 3 times and record.

VII. Clinical Evaluation Check each item as indicated. Check "NE" if not evaluated.

Normal Abnormal NE

Notes (Describe every abnormality in detail.

Include pertinent item number before each comment.)

1. General/Constitution

2. Mental / Affect / Mood / (Development-children)

3. Skin

4. Eye

5. Ears/Nose/Throat

6. Neck/Thyroid

7. Lungs/Thorax

8. Breasts

9. Cardiovascular (Record murmurs/abnormalities)

10. Abdomen

11. Male Genitalia

12. Anus/Rectum/Prostate (if indicated)

13. Musculoskeletal / Spine / Extremities (Note limitations)

14. Lymph Nodes

15. Neurologic

16. Female Gynecologic (if indicated)

Version 1.0, February 2019 9

IX. LABORATORY ANALYSIS: All tests are required unless otherwise specified.

COPIES OF LABORATORY REPORTS MUST BE SUBMITTED FOR REVIEW AND MUST BE IN ENGLISH

1. Hematology:

Hematocrit % or

Hemoglobin gms%

WBC ______________ /cmm

Platelets _________

2. Chemistry

Fasting Blood Sugar

HgA1C (if indicated)

Creatinine

ALT

3. Serology and Other Labs

HIV

RPR/VDRL_______

Hepatitis Panel _________

Urinalysis, complete ___ ________

4. Lipid Panel

Total Cholesterol_____

Triglycerides _____

HDL Cholesterol _____

LDL Cholesterol Calculation____

Total Cholesterol/HDL Ratio

5. Tuberculin Skin Test: Required (unless previously positive) Results: mm of induration Date:

Interferon Gamma Release Assay: (may substitute for TST in those with previous BCG) Results: Date:

If no TB screening performed, explain why:

Previous active tuberculosis Yes No Date:

Previous positive TST or IGRA Yes No Date:

Previous LTBI treatment Yes No Date:

Hx of BcG vaccine Yes No Date:

Other:_

6. Chest X Ray (PA and lateral) - submit report

• Required for those with > 10 mm TST newly identified or if positive IGRA

OR

• When clinically indicated

Results: Date:

7. ECG (50 years or older, earlier if indicated) - submit tracing

Results:_________________________________________________

Date:

8. Blood Type (if not previously documented) Type: ABO (Rh) Dµ: (weak D): ________________

9. G6PD (If not previously documented) for malaria prophylaxis Results: Date:

X. Assessment or Problem List XI. Recommendation for Treatment / Further Study / Consultation or Follow - Up

Printed Name of Examiner Signature of Examiner Date (mm-dd-yyyy)

Examining Facility Telephone Number

Address

Version 1.0, February 2019 10

VISION AND HEARING WORKSHEET – PLEASE COMPLETE

**BRING GLASSES OR CONTACTS TO THE VISION EXAM**

Examinee's Name SSN: Date:

VISUAL ACUITY

Please remove contacts for all uncorrected vision.

UNCORRECTED VISION (SNELLEN UNITS)

Far Vision Both 20/ Right 20/ Left 20/

Near Vision Both 20/ Right 20/ Left 20/

CORRECTED VISION (SNELLEN UNITS)

Far Vision Both 20/ Right 20/ Left 20/

Near Vision Both 20/ Right 20/ Left 20/

HEARING - WHISPER TEST

Can examinee hear whisper at greater than 5 ft.?

Right Ear YES or NO (circle one) Left

Ear YES or NO (circle one)

Hearing Aid Used?

Right Ear YES or NO (circle one) Left

Ear YES or NO (circle one)

Drum Perforation?

Right Ear YES or NO (circle one)

Left Ear YES or NO (circle one)

PERFORM A DECIBEL LOSS THRESHOLD AUDIOGRAM ONLY IF

EXAMINEE FAILS WHISPER TEST

AUDIOGRAM RESULTS: Please note decibel tested at each frequency per ear and attach printouts.

FREQUENCY(HZ) 500 1000 2000 3000 4000 6000 8000

Right Ear

Left Ear

Version 1.0, February 2019 11

PPD MANTOUX TEST

TO BE COMPLETED BY EXAMINEE

LAST NAME FIRST NAME MIDDLE INITIAL SOCIAL SECURITY NUMBER

Have you ever had . . .

1. A Mantoux or Tuberculosis (TB) test before? ................................................................. Yes............ No

Did the test indicate an exposure to TB?............................................................................ Yes………. No

If yes, date of last TB test: ………………

2. INH prophylaxis (preventative treatment)? ..................................................................... Yes........... No

If yes, date and duration of INH:…………………….

3. Treatment for active TB (several medicines)? ................................................................ Yes........... No

If yes, for how long? ……………………….

4. A BCG vaccine (shot to prevent TB)? ............................................................................ Yes........... No

I understand that I must return to the examining facility to have my PPD interpreted within 48-72 hours after it is administered.

Signature of Examinee: Date:

TO BE COMPLETED BY A TRAINED HEALTH PROFESSIONAL

1. ADMINISTER THE PPD MANTOUX (NOT PPD TINE) SKIN TEST.

• Test should not be administered if examinee has had a positive TB test, INH prophylaxis, or TB treatment in the past.

• Test should be administered if examinee has had BCG vaccine and NO KNOWN POSITIVE TB test.

a) Arm tested?....................................... Left .......... Right

b) Administered by:

printed name/signature/date

2. TEST RESULT MUST BE READ WTHIN 48-72 HOURS.

a) Induration (hardness): mm (If no induration, record “0” mm.)

Read by:

printed name/signature/date

****Chest X-ray required for an induration of >10 mm****

Date and result of last chest x-ray, if known:

b) NO-SHOW FOR READING PLANS TO GO ELSEWHERE FOR READING

Version 1.0, February 2019 12

Immunization Screening Questionnaire and Consent Form

Part I: PATIENT INFORMATION

Name: Social Security #: Date:

Date of Birth: Age: Telephone Number:

Part II: SCREENING QUESTIONNAIRE FOR IMMUNIZATIONS

Answer these questions by checking the boxes. If the question is not clear, please ask the medical professional administering the vaccines.

QUESTION YES NO

DON'T

1 Are you sick today?

Do you have any allergies to medications, food or vaccines?

Specify:

Have you ever had a serious reaction after receiving a vaccine?

Describe:

4 Have you ever had Guillain Barre Syndrome (GBS)?

Do you, any person who lives with you, or person you take care of have cancer, Leukemia, AIDS, or any other immune system problems?

Do you, any person who lives with you, or person you take care of take cortisone, prednisone, or other steroids, anti-cancer drugs, or radiation treatments?

7 Do you have a seizure, brain or nerve problems?

During the past year, have you received a transfusion of blood or plasma, or been given a medicine called Immune (gamma) Globulin?

9 Have you ever had Chicken Pox? If yes, at what age?

10 Has your Spleen been removed?

Have you received any vaccinations in the past four weeks?

Specify:

12 FOR WOMEN: Are you pregnant or is there a chance you could become pregnant in the next three months?

Part III: VACCINE CONSENT

I have had a chance to ask questions and they were answered to my satisfaction. I understand the benefits and the risks of the vaccine(s) and ask that the vaccine(s) be given to me. I agree to wait twenty minutes after receiving the injection(s) to be observed for any adverse reactions to the vaccine.

X

Signature of the person receiving the vaccine(s) Date

Part IV: VACCINE(S) ADMINISTERED BY ONSITE MEDICAL PROFESIONAL

VACCINE Dose / Route LOT# Manufacturer EXP. Site INITIALS

Hep A 1.0 ml / IM / / Hep B 1.0 ml / IM / / Twinrix 1.0 ml / IM / / Influenza 0.5 ml / IM / / MMR 0.5 ml / SC / / Polio 0.5 ml / SC / / Tetanus and Diphtheria (TD) 0.5 ml / IM / / Tetanus-Diphtheria-Pertussis (TDAP) 0.5 ml / IM / / Typhoid 0.5 ml / IM / / Varicella (Chickenpox) 0.5 ml / SC / / Yellow Fever, if applicable 0.5 ml / SC / / Other __ ml / / /

Please attach a copy of the Examinee's Immunization record if available

Signature of the person administering the vaccine(s) Date