DEMPS_Medical_Clearance.doc

Disaster Emergency Medical Personnel System (DEMPS) Medical Clearance Questionnaire and Certification of Ability

Name: ___________________________________ Last 4 of Social Security Number: __________

Occupation________________________________ Today’s date __________________________

1. Do you currently have work restrictions or have a disability? ___Yes ___No If yes, please describe: _______________________________________________

2. Do you take any prescription or over-the-counter medications/supplements?

___Yes ___ No If yes, please list: ____________________________________________________

3. Do you have any medication allergies?

___Yes ___ No If yes, please list: ______________________________________________

4. Do you now have or have you in the past had any of the following medical conditions? ___Yes ___No

If yes, please check:

___ High blood pressure ___ Heart disease

___ Diabetes

___ Mental illness ___ Asthma or emphysema ___ Sleep apnea

___ Epilepsy ___ Limited mobility of back or any extremity

5. Have you had surgery within the last 12 months ___Yes ___ No If yes, please describe the date and type of surgery: _________________________

6. Please indicate whether you require electricity for medical devices/medication refrigeration ___Yes ___No Special food or timing of meals ___Yes ___No Air conditioning for health reasons ___ Yes ___N o Assistance with health monitoring ___ Yes ___No Access to specialized medical care ___ Yes ___No

6. Has there been a change in your health or any change in your medications within the past year? __Yes __No If yes, please describe: __________________________________________________

7. DEMPS personnel may potentially be exposed to any of the following environmental and work conditions. I certify I have no restrictions in my ability to endure/perform:

Figure 1 - Form

7. Please check the statement below that indicates your ability to participate in the DEMPS program, including deployment:

_____ I do not have any medical disorder, physical impairment, or allergies that would interfere in any way with the full performance of the duties, as indicated above, as a participant in the DEMPS program.

_____ I am not physically able to participate in activities as outlined above.

Volunteer signature ___________________________________ Date ______________________ Immunization, Tuberculosis, and Prophylaxis Evaluation Name: _________________________ Last 4 of Social Security Number: __________ Date _____________________

Mumps

Measles

Rubella

#2

Tetanus/ diphtheria (Td)

X X

Influenza

X X

#2

X

#3

X

Hepatitis A Not mandatory #1

#2

Typhoid

intramuscular (IM) x 1 q 2 years.

Tuberculosis Evaluation

IGRA

result

Date of >

Prophylaxis/Treatment

Malaria Prophylaxis: See http://www.cdc.gov/malaria/travelers/drugs.html - usually Chloroquine 500 milligrams (mg), 1 po qd week 1-2 weeks before, during, and 4 weeks after deployment (7-8 weeks total); avoid Primaquine in glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Traveler's Diarrhea: See http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-2-the-pre-travel-consultation/travelers-diarrhea.htm - TREATMENT: Usually Azithromycin 500 mg po qd, dispense 3-pak

DEMPS Physical Examination Name: ______________________ Last 4 of Social Security Number: __________ Date of exam _______ Vital Signs

Physical Examination

Normal

Describe Abnormalities

General

Skin

Head, Eyes, Ears, Nose, Throat, (HEENT)

Heart

Lungs

Abdomen

Upper Extremities

Lower Extremities

Back

Nervous System

Mental Status

Other

Comments:

Employee Name: _________________________ Last 4 of Social Security Number: __________ Certification Expires: ____________________________ This evaluation was performed with reference to the Employee Occupational Health Guidebook, Chapter 10, http://vaww.ceosh.med.va.gov/01HP/Pages/guidebooks.shtml. and has been found to meet the following classification:

___ Class I: Those who are fully deployable to any response scenario without a medical or mental health condition likely to be exacerbated by work and living environments. They have no physical limitations, require no refrigerated medications, and are medically cleared for full respirator use.

___ Class II: Those who have stable chronic medical conditions with low probability of exacerbation if assigned to response duties with clearly delineated limitations.

Restrictions:

___ Class III: Those with unique, self-limiting illness or disease processes that may or may not be resolved at the time of needed deployment. Each volunteer must be considered on a case-by-case basis depending on the unique nature of the response mission. Class III personnel are advised on initial evaluation or during the annual spring assessment to contact Employee Occupational Health when their specific condition has resolved and they are returned to full duty. This group can be followed over the upcoming year, anticipating they will be reclassified as Class I.

____Class IV: Not qualified for participation

Signature Date