Attchmnt_3-IA_Template.pdf

Attachment A November 2011 Template

Appropriate Division Letterhead

Individualized Assessment – Medical Fitness for Duty Determination

GENERAL

Name of Individual:

Date of Birth:

Position Applied for:

Date Submitted:

Medical Officer Submitting Report:

Is this a fitness for dive duty determination? ___ Yes ___ No If yes, is diving a collateral duty? ___ Yes ___ No

MEDICAL HISTORY

This section should contain a discussion of the Report of Medical History form DD 2807, medical issues discovered during pre-employment physical exam, and all other medical information available from sources outside of the National Oceanic and Atmospheric Administration (NOAA) relating to the potentially disqualifying condition. It should include the opinions of doctors, rehabilitation counselors, physical therapists, other medical professionals, or others who have expertise in the specific disqualifying condition(s) or who have direct knowledge of the individual.

WORK HISTORY

This section should discuss jobs that have recently been performed by the applicant. If known, discuss how the applicant’s medical condition has affected his or her job performance.

REGULATORY GUIDANCE

Cite the NOAA medical standards that are being used to make this assessment. (For example as applicable: NOAA Fleet Medical Policy Manual, NOAA Dive Medical Manual, NOAA Aircraft Operations Center Medical Policy Manual, other scientific texts, and/or periodicals).

ABILITY TO PERFORM DUTIES

Using the position description or statement of duties as a guide, this section should contain a discussion regarding the individual’s capability to perform the job. The discussion should include missed sailings and any conflicts with appointments and being at sea. A direct relationship of duties to potentially disqualifying condition(s) must be demonstrated. This does not include the remote location/arduous, hazardous environment (this goes in the Direct Threat Assessment section).

Attachment A November 2011 Template

DIRECT THREAT ASSESSMENT

Example: Mr. Doe is a significant risk for substantial harm to the health or safety of self, others, or mission that cannot be eliminated by reasonable accommodation as supported by the following:

1. The duration of the risk.

Is the risk of harm (not the potentially disqualifying condition) ongoing? Is there an end date or resolution?

2. The nature and severity of the potential harm.

This includes an arduous and/or remote environment without medical care.

Documentation should include severity and type of harm (self, others, mission), and harm must be documented as ‘substantial harm.’

3. The likelihood that the potential harm will occur.

This must be demonstrated to be “significant risk” (not “remote risk”) and should be stated specifically.

4. The imminence of potential harm.

The risk must be shown to be current and ongoing, not some time in the future.

DISCUSSION

The above information is summarized. The medical history, the ability to do the job, and the direct threat analysis should all be correlated to clearly state the safety concern and potential poor outcome.

RECOMMENDATION

Example: As a result of the above discussion, Mr. Doe is not medically qualified for sea duty at this time to serve in the position of First Assistant Engineer.

The Director of Health Services will add a note of comment and/or concurrence here with signature before it leaves the Health Services division and is forwarded along the flowchart pathway.