Attachment 1 NBAF Occupational Health - The Contractor Guide.pdf

NBAF OCCUPATIONAL HEALTH

The Contractor’s Guide to Medical Deliverables

TABLE OF CONTENTS

Page Service

3 Medical Examination: Animal Allergens, Baseline, Periodic, and Termination

4 Medical Examination: Ethylene Oxide, Baseline, Periodic, and Termination

5 Medical Examination: Methylene Chloride, Baseline, Periodic, and Termination

6 Medical Examination: Noise, Situational

7 Medical Examination: Respiratory Protection, Baseline, Periodic

9 Medical Testing: 12-Lead Resting Electrocardiogram

10 Medical Testing: Audiometry

11 Medical Testing: Chest Radiography

12 Medical Testing: Pulmonary Function Test

13 Medical Testing: Tuberculin Skin Test

14 Medical Testing: Vision Screening

16 Vaccination List: Tuberculosis, Hepatitis A, Hepatitis B, Influenza, Rabies, Tetanus Diphtheria (Td),Tetanus, Diphtheria, Pertussis (Tdap)

15 Medical Testing: Q Fever AntibodyTest

8 Medical Examination: Tuberculosis Screening (Positive PPD or IGRA), Initial & Subsquent Encounter

MEDICAL EXAMINATION: ANIMAL ALLERGENS

6. Background Information

The purpose of the animal allergens medical examination is to assess for medical conditions or histories that would place the worker at increased risk of material impairment to health from exposure to animals, animal products, and/or animal components.

The animal allergens medical examination should be completed with consideration to the guidelines established in the current version of the “NRC Guide for the Care and Use of Laboratory Animals” and “AAALAC Occupational Health and Safety in the Care and Use of Research Animals”.

7. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

B. NBAF Occupational Health Program: ARS-182C Occupational Medical Surveillance Program Occupational /Medical Questionnaire (Allergies Section)

This medical examination should be scheduled with a physician or mid-level healthcare provider authorized to perform this examination as permitted within their scope of practice per their state practice act and/or state licensing board.

8. Program Requirements

The physician or mid-level healthcare provider performing this examination should complete, at a minimum, the following procedures:

• Review of “NBAF Occupational Health Program: Medical Questionnaire (Allergies Section)”

9. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Healthcare Provider’s Written Opinion: Animal Allergens

10. Miscellaneous

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

All laboratory testing will be completed at the Contractor's Location.

MEDICAL EXAMINATION: ETHYLENE OXIDE

1. Background Information

The purpose of the ethylene oxide medical examination is to assess for clinical evidence, including signs and symptoms of illness, caused by actual or potential exposure to ethylene oxide and/or ethylene oxide products that would place the worker at increased risk of injury, illness, impairment, and/or death.

This medical examination should be completed with consideration to current health and safety guidelines regarding potential and actual exposure to ethylene oxide in the workplace as established by the CDC, NIOSH, OSHA, and other pertinent authorities.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

This medical examination should be scheduled with a physician authorized to perform this examination as permitted within their scope of practice per their state practice act and/or state licensing board.

3. Program Requirements

The physician performing this examination will determine what is medically necessary to provide an informed medical determination.

However, the USDA COR or designated authority will automatically order the following tests per the medical surveillance protocols for diagnostic, laboratory, and specialty testing as approved and signed by the Competent Medical Authority (CMA) unless different recommendations are explicitly conveyed in writing to the USDA COR:

• Chest radiography, posteroanterior view only

• Electrocardiography, 12-lead

• Pulmonary function test

• Complete blood count w/ differential, blood

• Comprehensive metabolic panel, serum

• Urinalysis w/ microscopy, urine

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Physician’s Written Opinion: Ethylene Oxide

5. Miscellaneous

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

MEDICAL EXAMINATION: METHYLENE CHLORIDE

1. Background Information

The purpose of the methylene chloride medical examination is to assess for clinical evidence, including signs and symptoms of illness, caused by actual or potential exposure to methylene chloride and/or methylene chloride products that would place the worker at increased risk of injury, illness, impairment, and/or death.

This medical examination should be completed with consideration to current health and safety guidelines regarding potential and actual exposure to methylene chloride in the workplace as established by the CDC, NIOSH, OSHA, and other pertinent authorities. The attending healthcare provider performing this examination will be required to comply with the applicable standards and regulations specified in 29 CFR 1910.1052, including subsections and appendices.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

This medical examination should be scheduled with a physician authorized to perform this examination as permitted within their scope of practice per their state practice act and/or state licensing board.

3. Program Requirements

The physician performing this examination will determine what is medically necessary to provide an informed medical determination.

However, the USDA COR or designated authority will automatically order the following tests per the medical surveillance protocols for diagnostic, laboratory, and speciality testing as approved and signed by the Competent Medical Authority (CMA) unless different recommendations are explicitly conveyed in writing to the USDA COR:

• Electrocardiography, 12-lead

• Pulmonary function test

• Carboxyhemoglobin, blood

• Complete blood count w/o differential, blood

• Comprehensive metabolic panel, serum

• Lipid panel, serum

• Urinalysis w/o microscopy, urine

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Physician’s Written Opinion: Methylene Chloride

5. Miscellaneous

All laboratory testing will be completed at the Contractor's Location.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

MEDICAL EXAMINATION: NOISE

1. Background Information

The purpose of the noise medical examination is to assess for clinical evidence, including signs and symptoms of injury or illness, caused by actual or potential exposure to hazardous noise levels. This situational medical examination is tailored for a worker that has been exposed to hazardous noise levels either by a direct exposure to high impact noise and/or a confirmed standard threshold shift in audiometric testing results when comparing periodic and baseline results.

This medical examination should be completed with consideration to current health and safety guidelines regarding potential and actual exposure to hazardous noise levels in the workplace as established by the CDC, NIOSH, OSHA, and other pertinent authorities. The attending healthcare provider performing this examination will be required to comply with the applicable standards and regulations specified in 29 CFR 1910.95, including subsections and appendices.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

This medical examination should be scheduled with a physician authorized to perform this examination as permitted within their scope of practice per their state practice act and/or state licensing board.

3. Program Requirements

The physician performing this examination should complete, at a minimum, the following procedures:

• Review of audiometric test results to medically confirm a standard threshold shift.

• Complete causation analysis of the case to determine work-relatedness.

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Physician’s Written Opinion: Noise

5. Miscellaneous

All laboratory testing will be completed at the Contractor's Location.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

MEDICAL EXAMINATION: RESPIRATORY PROTECTION

1. Background Information

The purpose of the respiratory protection medical examination is to assess the medical status of the worker to determine the worker’s ability to use a respirator before respirator fit testing and usage.

This medical examination should be completed with consideration to current health and safety guidelines established by the CDC, NIOSH, OSHA, and other pertinent authorities. The attending healthcare provider performing this examination will be required to comply with the applicable standards and regulations specified in 29 CFR 1910.134, including subsections and appendices.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

B. NBAF Occupational Health Program: Respirator Medical Evaluation Questionnaire

This medical examination should be scheduled with a physician or mid-level healthcare provider authorized to perform this examination as permitted within their scope of practice per their state practice act and/or state licensing board.

3. Program Requirements

The physician or mid-level healthcare provider performing this examination should complete, at a minimum, the following procedures:

• Review of “NBAF Occupational Health Program: Respirator Medical Evaluation Questionnaire”

The physician performing this examination will determine what is medically necessary to provide an informed medical determination.

However, the USDA COR or designated authority will automatically order the following tests per the medical surveillance protocols for diagnostic, laboratory, and specialty testing as approved and signed by the Competent Medical Authority (CMA) unless different recommendations are explicitly conveyed in writing to the USDA COR:

• Pulmonary function test

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Contractor's Occupational Medicine: Medical Evaluation to Wear a Respirator Report

• Contractor's Occupational Medicine: Respirator Medical Evaluation Summary and Recommendations

5. Miscellaneous

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

All laboratory testing will be completed at the Contractor's location.

MEDICAL EXAMINATION: TUBERCULOSIS SCREENING (POSITIVE PPD OR IGRA)

1. Background Information

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

• NBAF Occupational Health Program: Medical Services Referral Form

This medical examination should be scheduled with a physician or mid-level healthcare provider authorized to perform this examination as permitted within their scope of practice per their state practice act and/or state licensing board.

3. Program Requirements

The physician or mid-level healthcare provider performing this examination should complete, at a minimum, the following procedures:

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

5. Miscellaneous

All laboratory testing will be completed at the Contractor's location.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services or specialty testing not listed in the referral form unless otherwise authorized by the USDA COR or designated authority via the USDA referral form. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

Medical assessment of worker's health status after a positive tuberculin skin test or IGRA test. This service is for an initial and follow-up medical assessment and consultation encounter only.

• Physician’s Written Opinion: Tuberculosis Screening results

• Recommended treatment plan after the worker's encounter.

• Obtain a release of medical information as needed to relay medical information about the encounter to the USDA COR (or designated authority).

• Chest x-ray

• Sputum sample

MEDICAL TESTING: 12-LEAD RESTING ELECTROCARDIOGRAM

1. Background Information

The 12-lead resting electrocardiogram is a test that measures the electrical activity of the heart as recorded by 10 electrodes placed on the body surface in specific locations to produce 12 different leads or views.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

3. Program Requirements

The contractor should complete, at a minimum, the following procedures:

• Electrocardiogram, 12-lead resting

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Copy of electrocardiogram results w/ interpretative comment(s)

5. Miscellaneous

This medical test should be interpreted by a physician, mid-level healthcare provider, registered nurse, or medical assistant as permitted within their scope of practice following Kansas state law. Test interpretation will be completed by a physician or mid-level as permitted within their scope of practice following Kansas state law.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

MEDICAL TESTING: AUDIOMETRY

1. Background Information

Pure-tone audiometric testing is a non-invasive hearing test that uses pure tones at different frequencies to measure hearing acuity.

Audiometric testing shall comply with the standards specified in 29 CFR 1910.95, including subsections and appendices.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

3. Program Requirements

The contractor should complete, at a minimum, the following procedures:

• Pure-tone audiometric testing of both ears.

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Copy of audiogram results w/ date and signature of tester

5. Miscellaneous

This service is only for testing. Test interpretation is not requested under this service line item. Test results will be provided to the USDA COR as specified in the contract.

Audiometric testing performed by an audiologist or audiology technician as permitted within their scope of practice following Kansas state law.

All laboratory testing will be completed at the Contractor's Location.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

MEDICAL TESTING: CHEST RADIOGRAPHY

1. Background Information

Chest radiography is an imaging test that uses a low dose of ionizing radiation to produce images of the inside of the chest.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

3. Program Requirements

The contractor should complete, at a minimum, the following procedures:

• Chest radiography, posteroanterior (1-view) only or posteroanterior and lateral (2-views) as specified in the referral form.

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Copy of the radiologist’s chest radiography interpretation report/letter w/ date and reviewer’s signature provided to the USDA COR as specified in the contract.

5. Miscellaneous

This medical test performed by a board-certified radiologist or radiology technician as permitted within their scope of practice following Kansas state law. Test interpretation is requested and will be performed by a board-certified radiologist as permitted within their scope of practice following Kansas state law.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

MEDICAL TESTING: PULMONARY FUNCTION TEST

1. Background Information

Spirometry testing is a non-invasive test that measures how much air you can breathe in and out of your lungs, as well as how easily and fast you can the blow the air out of your lungs.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

3. Program Requirements

The contractor should complete, at a minimum, the following procedures:

• Spirometry w/ expiratory testing (additional inspiratory testing will be accepted w/o further cost to the USDA).

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Copy of the spirometry report w/ date and reviewer’s signature. The report must contain at least the following results in numeric format: FVC, FEV1, and FEV1/FVC.

5. Miscellaneous

The reviewing healthcare provider will review and sign the spirometry report and provide it to the USDA COR as specified in the contract.

This medical test should be completed by a physician or mid-level as permitted within their scope of practice following Kansas state law.

Registered nurses or medical assistants may perform this test under direct supervision of the licensed physician or mid-level, or if the have completed a NIOSH-approved spirometry training course. Test interpretation is requested and will be performed by a physician or mid-level as permitted within their scope of practice per their state practice act and/or state licensing board.

All laboratory testing will be completed at the Contractor's Location.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

MEDICAL TESTING: TUBERCULIN SKIN TEST

1. Background Information

Tuberculin skin testing is the standard method of determining whether a person is infected with Mycobacterium tuberculosis, performed by injecting 0.1 ml of tuberculin purified protein derivative (PPD) into the inner surface of the forearm and interpreting the skin test reaction between 48 and 72 hours after administration. Tuberculin skin testing shall comply with the latest standards and guidance provided by the Centers for Disease Control and Prevention.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

3. Program Requirements

The contractor should complete, at a minimum, the following procedures:

• Tuberculin skin testing using purified protein derivative administered on the forearm.

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Copy of the tuberculin skin test report. The report must contain at least the following information: date of test administration, area of test administration (left/right forearm), PPD vial manufacturer, PPD vial lot number, PPD vial expiration date, date of test interpretation, test results (recorded in millimeters of induration), test interpretation (positive/negative), and test reviewer name w/ credentials (MD, DO, NP, RN, etc.).

5. Miscellaneous

This medical test should be completed by a physician, mid-level healthcare provider, registered nurse, or medical assistant as permitted within their scope of practice following Kansas state law is requested under this service line item. Testing procedures should follow the latest CDC guidelines. The contractor is expected to send the tuberculin skin test administration and interpretation record to the USDA COR as specified in the contract.

All laboratory testing will be completed at the Contractor's Location.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

MEDICAL TESTING: VISION SCREENING

1. Background Information

Vision screening is a brief non-invasive test that may assist in the detection of eye and/or vision problems. Vision screening should include bilateral assessment of visual acuity (far and near), depth perception, color perception, peripheral vision, and eye balance testing.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

3. Program Requirements

The contractor should complete, at a minimum, the following procedures:

• Vision screening including bilateral assessment of visual acuity (far and near), depth perception, color perception, peripheral vision, and eye balance testing.

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Copy of the vision screening report. The report must contain at least the following information: bilateral assessment of visual acuity (far and near), depth perception, color perception, peripheral vision, and eye balance testing.

5. Miscellaneous

This medical test should be completed by a physician, mid-level healthcare provider, registered nurse, or medical assistant as permitted within their scope of practice following Kansas state law. The contractor is expected to send the vision screening results to the USDA COR as specified in the contract.

All laboratory testing will be completed at the Contractor's Location.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

MEDICAL TESTING: Q FEVER ANTIBODY TEST

1. Background Information

Q fever is a disease with acute and chronic presentations caused by the bacterium Coxiella burnetii. Cattle, sheep, and goats are the primary reservoirs, although a variety of species may be infected. Detection of Coxiella burnetii DNA by polymerase chain reaction (PCR) can rapidly confirm an acute Q fever infection.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

3. Program Requirements

The contractor should complete, at a minimum, the following procedures:

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Copy of the PCR report w/ date and reviewer’s signature. The report must contain at least the following results: Date and time treatment was administered, etc...

5. Miscellaneous

This medical test should be completed by a physician or mid-level as permitted within their scope of practice following Kansas state law.

Registered nurses or medical assistants may perform this test under direct supervision of the licensed physician or mid-level, or if the have completed a NIOSH-approved spirometry training course. Test interpretation is requested and will be performed by a physician or mid-level as permitted within their scope of practice per their state practice act and/or state licensing board.

• DNA by polymerase chain reaction (PCR) of whole blood or serum

• Samples are ideally taken during the first 2 weeks of illness and before or shortly following proscribed treatment.

• Treatment should be initiated as soon as Q fever is suspected and should never be withheld pending the receipt of diagnostic test results.

All laboratory testing will be completed at the Contractor's Location.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

Service Description

Vaccination: Hepatitis A Hepatitis A vaccination.

Vaccination: Hepatitis B Hepatitis B vaccination.

Vaccination: Influenza Influenza vaccination.

Vaccination: Rabies Rabies vaccination.

Vaccination: Tetanus, Diphtheria (Td) Td vaccination.

Vaccination: Tetanus, Diphtheria, Pertussis (Tdap) Tdap vaccination.

2. Scheduling Requirements

The USDA COR or designated authority will provide the contractor with the following documents prior to scheduling an appointment:

A. NBAF Occupational Health Program: Medical Services Referral Form

This vaccination should be interpreted by a physician, mid-level healthcare provider, registered nurse, or medical assistant as permitted within their scope of practice following Kansas state law.

VACCINATION LIST

1. Information

3. Program Requirements

The contractor should complete, at a minimum, the following procedures:

4. Deliverables

The contractor should provide the following deliverables no later than two (2) business days from the service date:

• Contractor will send vaccine administration report/record evidencing this vaccination to the USDA COR

5. Miscellaneous

• Administer the vaccination identified on the NBAF Occupational Health Program: Medical Services Referral Form

All laboratory testing will be completed at the Contractor's Location.

Diagnostic and specialty testing will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

5. Miscellaneous

All vaccinations will be completed at the Contractor's Location.

Vaccinations will be completed at Contractor's Clinic only. Under no circumstances will the contractor be allowed to perform additional services not listed in the referral form unless otherwise authorized by the COR or designated authority. Any additional unauthorized services or commitment performed by the contractor will be completed at their own expense.

U.S. Department of Agriculture National Bio and Agro-Defense Facility

1980 Denison Avenue, Manhattan, KS 66502

NBAF Occupational Health Program: Medical Services Referral Form

I. WORKER INFORMATION

Name (Last, First, MI) Date of Birth (mm/dd/yyyy) Program, Unit, Section

Title, Series, Grade Appointment Preference

II. REQUESTED SERVICE(S)

A. Choose an item.

B. Choose an item.

C. Choose an item.

D. Choose an item.

E. Choose an item.

F. Choose an item.

G. Choose an item.

H. Choose an item.

I. Choose an item.

J. Choose an item.

K. Choose an item.

L. Choose an item.

Comments

III. APPOINTMENT INFORMATION

Appointment Date

Appointment Comments

IV. AUTHORIZATION INFORMATION

NBAF Representative’s Signature NBAF Representative’s Printed Name Date

Form Number:

Appointment Time Referral Expiration Date

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

OCCUPATIONAL/MEDICAL QUESTIONNAIRE

(See Form ARS-182A/B for Privacy Act Notification)

DEMOGRAPHIC INFORMATION

MALE FEMALE

EMPLOYEE'S MAILING ADDRESS (Where confidential mail can be delivered)

EMPLOYEE'S PHYSICIAN

EMPLOYEE'S CURRENT JOB

Have you ever been a resident outside the United States?

If yes, please list the location(s) and date(s). FROM

MONTH/YEAR

TO

MONTH/YEAR

1.

2.

3.

4.

5.

6.

Form ARS-182C (11/2000) Previous edition not usable

USDA-ARS

No Yes

JOB TITLE

BLACK/NOT HISPANIC ORIGIN

WHITE/NOT HISPANIC ORIGIN

HISPANIC

ASIAN/PACIFIC ISLANDER

AMERICAN INDIAN/

ALASKAN NATIVE

OTHER (specify):

SINGLE/NEVER MARRIED

MARRIED/LIVING TOGETHER

SEPARATED

DIVORCED

WIDOWED

LAST NAME FIRST NAME MIDDLE NAME

DATE OF BIRTH (mm/dd/yyyy)

STREET

LOCATION (City)

APARTMENT NO.

CITY STATE ZIP CODE

LAST NAME OFFICE TELEPHONE (Include Area Code)

STREET ADDRESS SUITE NO.

CITY STATE ZIP CODE

STATE ZIP CODE

REGULAR WORKPLACE (Building and Room No.) GS/WG SERIES

YEARS IN PRESENT JOB

RACE MARITAL STATUS

SEXSOCIAL SECURITY NUMBER

This form was electronically produced by USDA/ARS/ITD using INFORMS

EMPLOYMENT HISTORY

Start with the job you held before this one, and list all the jobs you ever had. Include military service and any part-time jobs.

COMPANY NAME AND JOB TITLE

FROM

MONTH/YEAR

TO

MONTH/YEAR POTENTIAL HAZARDS AND PERSONAL PROTECTIVE EQUIPMENT

Form ARS-182C (11/2000) (page 2)

USDA-ARS

SOCIAL SECURITY NO.

In your work are you now or have you ever been exposed to any of the following agents?

YES NO

Inorganic flourides

Lead

Benzene

Coke oven emissions

Inorganic arsenic

Methylene chloride

Vinyl chloride

Toluene diisocyanate

YES NO

Excessive noise

Nitrogen oxides

Crystalline silica

Nitric acid

Ammonia

Beryllium

Phosgene

Allyl chloride

YES NO

Asbestos

Suspect or known carcinogens

Pesticides

Bacteria or viruses

Primate animals

Vibrating tools

Radiation (Ionizing)

Radiation (Non-Ionizing)

If applicable, please elaborate on any positive responses above. Star (*) those that particularly concern you from a health standpoint.

Indicate any symptoms that you have experienced that might be due to exposure at work and indicate the suspected cause.

Form ARS-182C (11/2000) (page 3)

Have you experienced any job related illnesses or injuries since being employed by the USDA? No Yes

USDA-ARS

SYMPTOM: CAUSE:

IF YES, GIVE DETAILS: MONTH AND YEAR:

NO

PRE-

VIOUSLY

CUR-

RENTLY

Auto mechanic work

Auto body work

Been exposed to rubber cement for extended periods of time

Carpentry

Ceramics

Etching/metal work/jewelry/metal sculpture

Furniture refinishing

House painting

Lawn/Garden maintenance or farming

Make your own cartridges/salvage spent cartridges

Make your own fishing sinkers

Oil painting

Pottery

Recreational hunting/shooting

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

RECREATIONAL HISTORY

(Please print)

NO

PRE-

VIOUSLY

CUR-

RENTLY

Acids

Bonding agents or industrial glues

Cleaning fluids

Fertilizers

Gasoline or other petroleum products

Herbicides or weed killers

Insecticides/pesticides

Insulation material

Lacquer, varnish or enamel paints

Leather dyes

Paint thinners and removers

Soldering agents

Solvents/degreasers

Wood stains

SOCIAL SECURITY NO.

Do you now or have you in the past, done any of the following as a hobby or during your spare time?

Do you now or have you in the past, come into contact with any of the following during your spare time?

CIGARETTES: Have you ever smoked cigarettes regularly?

(If yes, please answer the following questions.)

("No" means never smoked, or smoked less than 20 packs of cigarettes or 12 ozs. of tobacco in life-time, or less than 1 cigarette a day for one year.)

a. How old were you when you started smoking cigarettes regularly?

b. Do you still smoke cigarettes?

If yes, how many cigarettes do you now smoke per day?

c. If you have stopped smoking cigarettes, how old were you when you stopped?

d. On the average, of the entire time you have smoked, how many cigarettes did you smoke per day?

e. Do, or did you inhale the cigarette smoke?

PIPES: Have you ever smoked a pipe regularly?

(If yes, please answer the following questions.)

("No" means never smoked, or smoked no more than 12 ozs. of pipe tobacco in your life-time.)

a. How old were you when you started smoking pipes regularly?

b. Do you still smoke pipes?

If yes, how many ounces of pipe tobacco do you now smoke per week?

c. If you have stopped smoking a pipe, how old were you when you stopped?

d. On the average, of the entire time you have smoked, how many ounces of tobacco did you smoke per day?

e. Do, or did you inhale the pipe smoke?

CIGARS: Have you ever smoked cigars regularly?

(If yes, please answer the following questions.)

("No" means never smoked, or smoked no more than 1 cigar a week for 1 entire year.)

a. How old were you when you started smoking cigars regularly?

b. Do you still smoke cigars?

If yes, how many cigars do you now smoke per day?

c. If you have stopped smoking cigars, how old were you when you stopped?

d. On the average, of the entire time you have smoked cigars, how many cigars did you smoke per day?

e. Do, or did you inhale the cigar smoke?

TOBACCO CHEWING: Have you ever chewed tobacco regularly?

(If yes, please answer the following questions.)

a. How old were you when you started chewing tobacco regularly?

b. Do you still chew tobacco?

c. If you have stopped chewing tobacco, how old were you when you stopped?

SNUFF: Have you ever used snuff regularly?

(If yes, please answer the following questions.)

a. How old were you when you started using snuff regularly?

b. Do you still use snuff?

c. If you have stopped using snuff, how old were you when you stopped?

ALCOHOLIC BEVERAGES: Do you now or have you ever drunk alcoholic beverages (such as wine, beer, or hard liquor) regularly?

(If yes, please answer the following questions.)

a. Which of the following do you regularly drink? (Check all that apply.)

b. Have you stopped drinking regularly?

If yes, how many years ago did you stop?

c. How much do (did) you drink on an average day or in an average week?

Wine

Beer

Liquor

EXERCISE: Do you get exercise on a regular basis?

Form ARS-182C (11/2000) (page 4)

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

(If yes, please answer the following questions.)

a. How many days per week?

b. How many minutes do you exercise?

c. Describe the kind of exercise you get:

No Yes

No Yes

Years

Cig./da

Years

Cig./da

Years

No Yes

Ozs./week

Years

Ozs./week

No Yes

Years

No Yes

Cigars/day

Years

Cigars/day

No Yes

Years

No Yes

Years

Years

No Yes

Years

DIET:

a. Do you drink more than two cups of coffee or tea a day?

b. Do you restrict your diet?

(If yes, which of the following items do you restrict?)

Meat

Sugar

Other (describe):

Sodium or Salt

Foods high in cholesterol

c. How many years have you been restricting your diet?

d. Why are you restricting your diet?

Religious reasons

Medical reasons

Other (describe):

Years

Days/week

Minutes

Years

SMOKING HISTORY LIFE-STYLE HISTORY

Less than 1 drink per day, or less than 7 drinks per week.

1 to 2 drinks per day, or 7 to 17 drinks per week.

3 to 4 drinks per day, or 18 to 31 drinks per week.

5 or more drinks per day, or more than 31 drinks per week.

USDA-ARS This form was electronically produced by USDA/ARS/ITD using INFORMS

CARDIOVASCULAR: Have you ever had or do you now have any of the following illnesses or problems with your heart or blood vessels?

RESPIRATORY ILLNESS/CONDITIONS: Have you had or do you now have any of the following illnesses or problems with your lungs?

NO

YES

PAST

YES

CURRENT

Frequent Colds Coughed up Blood

Chronic Cough

Lung or Breathing difficulties or Shortness of Breath

Asthma

Emphysema

Pneumonia

Tuberculosis

Bronchitis

Pleurisy

Other (specify):

Have you ever had surgery on your lungs?

(If yes, describe):

ENDOCRINE: Have you ever had or do you now have any of the following illnesses or conditions?

NO

YES

PAST

YES

CURRENT

Hypoglycemia Diabetes

Goiter

Thyroid disease or disorder

Swollen glands or nodes

Pancreatitis

Other gland problems (specify):

DIGESTIVE SYSTEM: Have you ever had or do you now have any of the following illnesses or problems with your digestive system?

NO

YES

PAST

YES

CURRENT

Blood in stool

Stomach or Duodenal Ulcer

Appendicitis

Nervous stomach

Colitis

Frequent constipation

Frequent diarrhea

Frequent indigestion

Stomach pain

Hiatal hernia or rupture

Diverticulitis

Hemorrhoids or piles

Other (specify):

Have you ever had surgery on your digestive Have you ever had surgery on your digestive tract?

(If yes, describe):

LIVER AND SPLEEN: Have you ever or do you now have any of the following illnesses or problems with your liver, spleen, or gallbladder?

NO

YES

PAST

YES

CURRENT

Cirrhosis of the liver

Hepatitis

Jaundice

Gallbladder disease

Gallbladder stones

Injury to your spleen

Other (specify):

Have you ever had surgery on your liver or spleen?

(If yes, describe):

KIDNEYS/URINARY TRACT: Have you ever had or do you now have any of the following illnesses or problems with your kidneys or urinary tract?

NO

YES

PAST

YES

CURRENT

Blood in urine

Pain or burning when urinating

Kidney disease

Kidney infection

Kidney stones

Nephritis (Bright's Disease)

Bladder Infection

Prostate gland enlargement/infection (Males only)

Tumor in urinary tract

Other (specify):

Have you ever had surgery on your kidneys or urinary tract? (If yes, describe):

Form ARS-182C (11/2000) (page 5)

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

MEDICAL HISTORY

NO

YES

PAST

YES

CURRENT

Nasal passages frequently irritated Nose Bleeds often

Throat is often irritated

Voice is hoarse when you do not have a cold

Mouth/Gums frequently have sores/ulcers

Gums shrinking, irritated or bleeding

Other (specify):

Have you ever had or do you now have any of the following problems with your mouth, nose or throat?

USDA-ARS

Have you ever had heart surgery? (If yes, NO

YES

PAST

YES

CURRENT

Heart Attack

Angina Pectoris

Heart Murmur

Enlarged Heart

Stroke

High Blood Pressure

Other problems with blood pressure

Episodes of chest pains, tightness, discomfort

Rheumatic Heart Disease

Arteriosclerosis

Varicose Veins

Other (specify):

MEDICAL HISTORY (Continued)

REPRODUCTIVE HISTORY (please answer all four questions):

a. Have you or your partner ever had a problem conceiving a child? Yes No

If yes,

b. Have you or your partner consulted a physician for a fertility or other reproductive problem? Yes No

If yes, specify who consulted the physician:

c. Have you or your partner ever conceived a child resulting in a miscarriage, still birth, or deformed offspring? Yes No

If yes, specify:

If outcome was a deformed offspring, what was the deformity?

Was this outcome a result of a pregnancy of yours with:

d. Did the timing of any abnormal pregnancy outcome coincide with your present employment? Yes No

List dates of occurrences:

What is the occupation of your partner?

NERVOUS SYSTEM: Have you ever had or do you now have any of the following illnesses or problems with your nervous system?

BLOOD: Have you ever had or do you now have any of the following blood diseases or problems?

Have you ever had a blood transfusion?

NO

YES

PAST

YES

CURRENT

Arthritis or Rheumatism

Gout

Joint pains

Bone infections

Bursitis or tendonitis

Backache, back trouble, sciatica

Foot trouble, flat feet or fallen arches

"Trick", "locked", or "loose" knee

Back injury or herniated disk

Painful or trick shoulder

Swollen or painful joints Other problems with your bones or joints (If yes, specify):

BONES AND JOINTS: Have you ever had or do you now have any of the following problems with your bones or joints?

Form ARS-182C (11/2000) (page 6)

NO

YES

PAST

YES

CURRENT

Frequent headaches

Migraine headaches

Epilepsy, convulsions, seizures

Nervous breakdown

Depression/Excessive worry

Loss of memory (amnesia)

Nervousness

Tremor of the hands or head

Palsey or tremors

Severe head injury

Neuritis

Paralysis of any type

Other problems (specify):

NO

YES

PAST

YES

CURRENT

Anemia Low hemoglobin

Bleeding disorder

Leukemia

Sickle cell disease or trait

Phlebitis

Other problems (specify):

If yes, specify the diagnosis:

Have you ever had surgery (including setting of broken bones) on any of your bones or joints? (If yes, describe):

SKIN: Have you ever had or do you now have any of the following skin problems?

NO

YES

PAST

YES

CURRENT

Hives

Eczema

Psoriasis

Rash on elbows, knees, or scalp

Rash other than on elbows, knees, or scalp

Severe stubborn dandruff Small itching blisters on the sides of your fingers or palms

Excessive sweating on palms, soles, or armpits

Sores that do not heal

Moles that bleed or get larger

Change in color of skin (other than suntan)

New growth on skin

Other (If yes, describe):

USDA-ARS

(NOTE: This section continues at top of next page.)

NO

YES

PAST

YES

CURRENT

Food Soaps or detergents

Chromium

Nickel

Rubber

Epoxy resins

Plants (e.g., poison ivy, etc.)

Pollen

Insect scales

Bee stings

ALLERGIES: Have you ever had or do you now have any allergies?

NO

YES

PAST

YES

CURRENT

Medications (If yes, please list):

Self Present Partner

Previous Partner

Self Partner Self and Partner

Miscarriage Still Birth Deformed Offspring

Present Partner A Prior Partner

NO

YES

PAST

YES

CURRENT

House dust

Animal dander, feathers, or fur

Sunlight or cold

Other (If yes, please list):

Do you react with:

Rash

Hives

Hay fever symptoms

Breathing difficulty

Other (If yes, describe):

Do you wear glasses?

Do you wear contact lenses?

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

MEDICAL HISTORY (Continued)

CANCER: Have you ever been diagnosed with cancer?

Type Year Specific Tissue Diagnosis (If available)

Skin

Colon

Breast

Lung

Prostate

Cervical

INFECTIOUS/CHILDHOOD DISEASES: Have you had or do you now have:

NO

YES

PAST

YES

CURRENT

Mononucleosis

Meningitis

Malaria

Polio

Rheumatic fever

Scarlet fever

Mumps

Measles

Chicken pox

German measles

Tonsillitis

Gonorrhea

Syphilis

FAMILY HISTORY: Have any of your blood relatives (parents, grandparents, brothers, sisters, aunts, uncles or children) had any of following the illnesses or conditions? NO

YES

PAST

YES

CURRENT

Anemia

Alcoholism

Allergies

Arthritis

Asthma

Bleeding disorders (free bleeder)

Breast cancer

Cervical cancer

Chronic bronchitis

Congenital malformations (birth defect)

Diabetes (sugar)

Digestive or bowel disease

Eczema

Emphysema

Epilepsy

Glaucoma

Gout

Hay fever

Heart attack

Heart disease

High blood pressure

Kidney or bladder disease

Kidney stones

Liver or gallbladder disease

Lung cancer

Mental illness

Learning disabilities

Nervous system disease

Psoriasis

(NOTE: This section continues at top of next page.)

Form ARS-182C (11/2000) (page 7)

No Yes (If yes, list the year and type of diagnosis.)

Other (If yes, specify type and describe tissue diagnosis and year):

EYES: Have you ever had or do you now have any of the following problems with your eyes or your vision?

NO

YES

PAST

YES

CURRENT

Glaucoma

Cataracts

Conjunctivitis (pink eye)

Blurring of eyesight

Vision getting worse

Seeing double

Seeing halos around lights

Pain in the eyeball

Eyes are often bloodshot

Other problems with your eyes (If yes, describe):

Right eye

Left eye

Injured (e.g., scratched, burned, cut, etc.)

Right eye

Left eye

Foreign object accidentally embedded in the eye

EARS: Have you ever had or do you now have any of the following problems with your ears or your hearing?

NO

YES

PAST

YES

CURRENT

Difficulty in hearing

Tinnitus (ringing/buzzing) in right ear in left ear

Nasal allergy

Vertigo (dizziness)

Perforation of the ear drum

Ear drainage (caused by infection or injury)

High fever

Infection of inner ear Hearing loss, permanent or temporary

Other problems with your ears (If yes, describe):

USDA-ARS

ALLERGIES (Continued)

MEDICAL HISTORY (Continued)

SOCIAL SECURITY NO.

FAMILY HISTORY (Continued)

NO

YES

PAST

YES

CURRENT

Sickle cell disease or trait

Stroke

Thyroid disease

Tuberculosis (T.B.)

Ulcer (stomach, duodenal, peptic)

Other cancers or leukemia

MEDICATIONS: Have you taken any of the following medications?

NO

YES

PAST

YES

CURRENT

Antacids

Antibiotics (e.g., penicillin, ampicillin, tetracycline)

Antihistamines

Aspirin

Benzedrine / Dexedrine

Birth control pills

Blood thinners (anti-coagulants)

Codeine

Cortisone or other steroids

Diet pills

Digitalis or other heart pills

Diuretic or water pills

Hormones

Insulin or oral anti-diabetic drugs

Iron pills

Laxatives

Morphine

Nitroglycerine

Pain killers (aspirin, empirin, anacin, bufferin, etc.)

Pep pills or mood elevators

Pills to lower your blood pressure

Sleeping pills

Sulfa preparations

Thyroid medication

Tranquilizers, sedatives, or nerve pills

Vitamins

Others

IMMUNIZATIONS, VACCINES, ANTITOXINS: If you have received any of the following, check the appropriate box(es) and give the approximate dates, if known.

Positive NegativeResults:

HISTORY OF HOSPITALIZATION: Have you been hospitalized in the past 10 years?

(If yes, list reason(s) and date(s) of hospitalization.)

Do you have any problems you would like to discuss with our physician?

Form ARS-182C (11/2000) (page 8)

SIGNATURE AND DATE COMPLETED

(Mo.) (Day) (Yr.)

USDA-ARS

If not, please give age at death:

and cause of death:

If not, please give age at death:

and cause of death:

(If yes, please list them):

Tetanus

Poliomelitis

Influenza

Typhoid

Diptheria

Rabies

Rubella (German measles)

Measles (Rubeola or red measles)

BCG

Yellow Fever

Smallpox

RhoGAM (Rh immune globulin)

Immune serum globulin for hepatitis

Date (mm/dd/yyyy)

No Yes

No Yes

Others (please list):

Mantoux, patch test, or other skin test for tuberculosis

Years

Years

This form was electronically produced by USDA/ARS/ITD using INFORMS

No YesIs your mother still living?

Is your father still living? No Yes

Are you aware of any disease or illnesses that run in your family? (If yes, please list below):

No Yes

NBAF Respirator Medical Evaluation Questionnaire (Mandatory)

Part A. Section 1. (Mandatory) Every employee who has been selected to use any type of respirator (please print) must provide the following information. Today's date

Name Job Title

Height Weight(ft) (in) (lbs)

Age

Phone Number Home: Work:

Male Female

Have your employer told you how to contact the health care professional who will review this questionnaire (Select one): Yes NO

Check the type of respirator you will use (you can check more than one category):

a N, R, or P disposable respirator (filter-mask, non-cartridge type only).

Powered-air purifier

Supplied-air

Self-contained breathing apparatus

Half-face

Full-facepiece type, Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who hasbeenselected to use any type of respirator (please select ``yes'' or ``no'').

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?

2. Have you ever had any of the following conditions?

Seizures (fits)

Diabetes (sugar disease)

Allergic reactions that interfere with your breathing

Claustrophobia (fear of closed-in places)

Trouble smelling odors

3. Have you ever had any of the following pulmonary or lung problems?

Asbestosis

Asthma

Chronic bronchitis:

Emphysema:

Pneumonia

Tuberculosis

Silicosis

Pneumothorax (collapsed lung)

Lung cancer

Broken ribs:

Any chest injuries or surgeries:

Any other lung problem that you've been told about:

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

Yes NO

NOAA Respirator Clearance (1) b

Have you worn a respirator(Select One):

Name If ``yes,'' what type(s):

Consistent with NOAA OSHA Respirator Medical…