Attmt 22 Non Mental Health Template.pdf

Attachment 22: Non Mental Health Decision Template

[Date]

Department of Homeland Security US Customs and Border Protection [Addressee Office] [Addressee Street Address, Room/Suite #] [Addressee City, State, Zip Code] Attn.: PCS COR

Name: ________________________ Applicant ID(s): [#######] Vendor ID(s): [#######] Position(s): _____________________ Consult request date: _____________ Revision date (if applicable): ________________ Consult type: Non-Psychiatric Medical Qualification

I have reviewed [##] pages of information in response to your request for a consultation.

Medical Findings Overview: Document important/relevant facts from the applicant’s medical history that are being reviewed in relation to medical qualification for the position.

Condition Specific Summary: Complete this section for each diagnosis, issue, condition, or medication being reviewed.

Diagnosis, Issue, Condition, or Medication

1. Status:

a. Meets Minimum Medical Qualifications (MMMQ)

i. If an issue is cleared, indicate if it is because the issue is resolved, in remission, or unlikely to affect job duties.

ii. Provide rationale regarding why the issue does not pose a risk to the applicant or others.

iii. Provide rationale regarding why the issue does not prohibit the applicant from performing essential functions of the job.

b. Does NOT Meet Minimum Medical Qualifications (DNMMMQ) - Indicate if the condition constitutes current and/or active symptoms, lack of documented period of stability, or risk of recurrence based on reasonable medical judgment. Describe risks posed by the condition considering:

i. Duration of the risk [How long the applicant has had the condition and how long it is expected to continue, the expected prognosis for recovery. If the concern is a lack of documented stability, indicate the minimum duration of stability required (6 months, one year, etc.)

before reassessing the condition. Also include what additional documentation would be recommended to demonstrate control of the medical issue/condition. For non-active conditions likely to recur, indicate the risk of recurrence (low, medium, high) and any predictable triggering or precipitating conditions to such recurrence.]

ii. Nature and severity of the harm [Examine how the condition is manifesting for the applicant currently, and how that condition will manifest on the job. Will it impact decision-making, impulse control, ability to perceive and react to high-stress, time-critical situations, interacting with the public in a professional matter, etc.? In short, what harm is likely to occur if this employee were in the position?]

iii. Likelihood harm will occur [In your opinion, are there aspects of the job that are likely to exacerbate the condition in question and, based on the applicant’s current status, what is the likelihood that the condition will manifest itself in a manner that places the applicant, his/her co-workers, or the public at risk in the workplace or unable to do a core task? For active conditions which are asymptomatic or former conditions which may reoccur, describe the probability of recurrence of symptoms or the condition while on the job and the likely harm/effect of such recurrence while on the job.]

iv. Imminence of harm In your opinion, how quickly may the individual experience a significant loss of functional capability (e.g., a sudden incapacitating event vs. subtle change in function)?

c. Insufficient information to make a medical qualification determination.

i. List the specific medical or non-medical information required to make a medical qualification determination in bullet points.

2. Nexus: Provide a nexus when the recommendation is “Does Not Meet Minimum

Medical Qualifications.”

a. Indicate specific tasks likely to be affected by present or likely to reoccur symptoms (or from medications for such conditions). Tasks may be identified in the job task analysis/job studies/position description; tasks may also be identified from the compiled job tasks lists.

b. Accommodation/mitigation. [Explain what potential accommodation/ mitigating factors exist (Is the applicant able to adequately identify deteriorating conditions, do they have coping mechanisms, etc.), medical OR non-medical, that the applicant can employ to mitigate worsening symptoms.

Will the individual be able to timely recognize a deteriorating condition and mitigate the risk? Will compliance with treatment, medication, diet, exercise, healthy lifestyle etc. reduce the chances of an incapacitating event or reduce the severity of an episodic event? Has applicant shown compensatory methods? If the applicant’s physician has provided potential accommodations, please explain whether you believe those would be (in)effective and why. Describe any accommodations you believe may enable the applicant to safely perform the essential functions of the position.] Explain how you reached your conclusion on these accommodations or mitigating factors. If your conclusion is different than that of the applicant’s provider, explain why.

c. Direct Threat of significant risk of substantial harm Given the nature of the condition (1.b. and 2.a) in light of accommodations/mitigation (2.b), provide an opinion and explicit rationale why the applicant poses a direct threat, i.e., a significant risk of substantial harm to the health and safety of him/herself, others including fellow employees, or the public which cannot be eliminated or reduced to an acceptable level by accommodation/mitigation.1 [i.e., explain why current medication or therapies are unlikely to reduce the risk to an acceptable level]. This risk assessment should be undertaken with full recognition of the unique requirements of the position including the conditions under which they are performed. While it may not be possible to predict how an applicant’s condition will exactly react or manifest while performing the functions of the job, please explain how certain job duties may make it more or less likely that the applicant presents a significant risk of substantial harm to themselves or others.

Overall Recommendation:

[Applicant name] meets or does NOT meet minimum medical qualifications for [Position].

[Applicant name] has provided insufficient information for all issues reviewed to make a medical determination for [Position]. NOTE: If one or more issues is found DNMMMQ, overall recommendation should be DNMMMQ.

The following issue(s) were not addressed in this recommendation:

[“None” or list remaining issues]

1 According to the EEOC, the "direct threat" evaluation must be based on an individualized assessment of the individual’s present ability to perform the essential functions of the job with or without reasonable accommodation.

If no accommodation exists to enable such performance, CBP may refuse to hire an applicant. In order to exclude an individual on the basis of future possible injury, CBP bears the burden of demonstrating that there is a significant risk, i.e., a high probability, of substantial harm; a speculative or remote risk is insufficient as CBP must show more than that an individual with a disability seeking employment stands some slightly increased risk of harm. Except in cases of a most apparent nature, the finding must consider and be based on substantial information regarding the individual's work and medical history. As part of this individualized assessment, CBP must examine adaptive behaviors and prior work experience. The results of an applicant’s medical tests alone will rarely constitute adequate evidence that s/he poses a significant risk of substantial harm to the health and safety of self or others which cannot be eliminated or reduced to an acceptable level.

[Signature] [Name and Credentials]