Attachment 10 - Forms.pdf

1) FD – 1126 – AUTHORIZATION FORM FOR ALL FBI EXAMS AND MEDICAL SURVEILLANCE

2) DS – 6561- OVERSEAS PRE-ASSIGNMENT MEDICAL HISTORY AND EXAMINATION

3) DS – 6570 – PRE-DEPLOYMENT PHYSICAL EXAM ACKNOWLEDGEMENT FORM

4) FD – 967 – FBI NEW AGENT PHYSICAL ACTIVITIES

5) FD – 1065 – FBI REPORT OF MEDICAL HISTORY

6) FD – 1093 – FBI REPORT OF MEDICAL EXAMINATION (PERIODIC EXAMS)

7) FD – 900 – FBI HAZARDOUS MATERIALS RESPONSE RESPIRATORY MEDICAL EVALUTION

QUESTIONNAIRE

8) FD – 899 – FBI RESPIRATORY CLEARANCE AND HAZARDOUS MATERIALS RESPONSE

MEDICAL REPORT

FBI FORMS LIST

Requester should refer to the COMPLETION INFORMATION SHEET and STATEMENT OF WORK Only those items requested will be completed by the vendor

FEDERAL BUREAU OF INVESTIGATION

AUTHORIZATION FORM FOR ALL FBI EXAMS AND

MEDICAL SURVEILLANCE

TO: (Vendor Physical Location)

FROM: FBI OFFICE – PLEASE WRITE

DIVISION and RA (if Applicable)

Division POC: POC Phone:

Examinee: 67 Number:

Date of Birth: Position Title:

Type of Exam: PE Periodic Applicant Hazardous Response Department of State

Other specify: ______________________________________________________________________________________________

Dates Requested #1:______________________#2:____________________#3: ____________________ Exam components for PE Periodic exams are already marked, please make sure to ADD tests and forms for all other exam types.

The Basic Occupational Health Exam Components (If you don’t need an item PLEASE REMOVE THE X)

Department of State Exams

Complete Blood Count with Differential HIV I and HIV II Renal and Metabolic Panel Hemoglobin A1C (FOR KNOWN DIABETICS) Lipid Panel DOS Form DS-6570 ESCAPE FORM Urinalysis DOS Form DS-6561 – PHYSICIAN MUST

COMMENT ON ALL POSITIVE RESPONSES Audiometry Mantoux Test for TB – unless prior history of conversion (APPLICANTS and DOS exams cannot self- read)

Other:

Distant Visual Acuity WITHOUT and WITH correction (if correction needed)

Additional Tests, Lab work and/or Forms (À la carte) Blood Group and Type

Near Visual Acuity WITHOUT and WITH correction (if correction needed)

G6PD

Field of Vision Audiometry (Stand Alone) Resting EKG, 12 lead with interpretation Hepatitis B Surface Antigens Exam History, Vitals (Height, weight, BP, Pulse, Temp) AND Written Summary of Findings.

Hepatitis B Antibodies

FD-1065 (Medical History Form) and FD-1093 (Report of Medical Exam Form) Review and Completion

Hepatitis C Antibodies

Pre-Employment/Applicant add On Tests or Lab Work Blood Lead and Zinc Protoporphyrins (ZPP) Pulmonary Functions Test (Spirometry) Plasma and RBC Cholinesterase: ONE DRAW Color Vision (Ishihara) Plasma and RBC Cholinesterase: TWO DRAWS Applicant Activity Form FD-967 Chest X-ray (PA and Lateral):

Additional Forms for Specialty Exams Pulmonary Function Test (Spirometry) Respiratory/HazMat Forms FD-899 and FD-900 Other:

Hazardous Devices School Form FD-1097 Other:

Diver Addendum Form FD-1065a Other:

Standard Vaccines Travel Vaccines Special Use Vaccines UPDATE ALL STANDARD VACCINES in accordance with the SOW guidelines (to be used in divisions without nurses only)

UPDATE THE FOLLOWING

TRAVEL VACCINES in accordance with the SOW guidelines – Country Specific

Note for special Use Vaccines: Please refer to the Statement of Work for guidance

Hepatitis A Typhoid Anthrax Hepatitis B Vaccine Yellow Fever Smallpox Twinrix Rabies Japanese Encephalitis MMR Seasonal Influenza (OCONUS

ONLY)

Inactivated Polio Travel Medications – Refer to SOW Tetanus/Diphtheria OR Tetanus/Diphtheria/Pertussis

Anti-Malarial Medication

Meningitis Antibiotics for Travelers Diarrhea

Varicella Medication for Altitude Sickness Travel Consultation and Education

Signature of FBI Requester: Date:

(OHN/FFDC/Applicant Coordinator)

FD-1126

Revised

06/08/2018

7. SSN of Employee (for Employee only)

10. Post of Assignment and Estimated Dates of Arrival / Departure (if known)

11. Details of Assignment (Check all that apply)

a. Proposed Post:

b. Present Post: EDD (mm-dd-yyyy)

EDA

(mm-dd-yyyy)

Frequent TDY

Iraq

AFG

Other ESCAPE Post/Name:

Other:

9. EMPLOYMENT STATUS:

Civil Service WAE PSC Contractor / Bureau or Office:

DOD ContractorLocally Engaged Staff DOD Civilian

Contractor (include name of contracting company and assoc. USG Agency):

LNA Other:

DS-6561

07-2017

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.

13. Telephone number of examinee or parent of child < 18 y/o (Where you can be reached for the next 90 days)

12. Email Address of examinee or parent of child < 18 y/o (Where you can be reached for the next 90 days)

PRIVACY ACT STATEMENT

AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C.4084).

PURPOSE: The information solicited on this form will be used to make appropriate medical clearance decisions.

ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order. More information on routine uses can be found in the System of Records Notice State-24, Medical Records.

DISCLOSURE: Providing this information is voluntary; however, not providing requested information may result in the failure of the individual to obtain the requisite medical clearance pursuant to 16 FAM 211.

OVERSEAS PRE-ASSIGNMENT MEDICAL HISTORY AND EXAMINATION

Non-Foreign Service Personnel and Their Family Members

OMB APPROVAL NO. 1405-0194

EXPIRATION DATE 07/31/2020

ESTIMATED BURDEN: 1 HOUR*

PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and /or recommendation for reducing it, please send them to: M/MED/EX, Room L101 SA-1, U.S. Department of state, Washington, DC 20522

U.S. Department of State

Bureau of Medical Services, M/MED, Room L101, SA-1, Washington, DC 20522- 0102

I. DEMOGRAPHIC INFORMATION

TO BE FILLED OUT BY EXAMINEE (OR PARENT for EXAMINEE < 18 Y/O)

DATE OF EXAM (mm-dd-yyyy)

1. Name of Examinee (Last, First, MI) 2. If Eligible Family Member, Name of Employee:

3. U.S. Govt. Agency and Branch: 5. Sex4. Date of Birth (mm-dd-yyyy)

Male Female

8. Status

Spouse Dependent ChildEmployee Domestic Partner

6. Place of Birth (for Employee and all Eligible Family Members)

For all applicants, employees or eligible family members::

39. Is there any other medical or mental health condition not covered in questions 1 - 38? Explain:

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

IIA. Explanations required for "Yes" answers to questions 1-39. Attach additional sheets as needed.

Yes No

Children Only: 34. Has your child been referred for any current or potential special educational services, accommodations, or modifications (i.e.: IFSP, Early Intervention, IEP, 504 Plan)? Explain:

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

35. Date of last PAP test? Results:

36. Date of last Mammogram? Results:

Are you pregnant? Est. due date:Yes No

IN THE PAST SEVEN (7) YEARS (for questions 29-33) (parents - please answer for children < 18 years of age)

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:

difficulty in relaxing or calming down, panicky feelings, irritability, anger, feeling hyper, or nervousness?

Name of Examinee

Do you (or your child) have a hisory of:

(parents - please answer for children < 18 years of age)

Yes

1. Frequent/severe headaches or migraines?

2. Fainting or dizzy episodes?

No

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 any cigarettes 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?

DOB

II. MEDICAL HISTORY

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

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.

21. Rheumatologic disorder?

Yes

22. Anemia?

No

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?

Date (mm-dd-yyyy) V. SIGNATURE OF EXAMINEE OR PARENT OF CHILD <18 Y/O (I certify I have read and understand the above statement.)

Any knowing and willful omission, falsification, or fraudulent statement regarding material medical information may constitute a criminal offense under 18 U.S.C. § 1001, and individuals committing such an offense may be subject to criminal prosecution. Employees of the United States Government also may be subject to disciplinary action, up to and including separation, for any knowing and willing omission or falsification or fraudulent statement of material information.

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

Yes No

DS-6561

Men/Women: Colon Cancer Screening:

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

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

Test (colonoscopy/sigmoidoscopy/guiacFOBT):

Results:

Yes No

DS-6561 Page 3 of 4

Name of Examinee DOB

V. INSTRUCTIONS FOR COMPLETION AND SUMBISSION OF FORM DS-6561

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 / SPONSOR / PARENT

• All fields on page 1 and 2 must be filled out. Examinee or parent/employee sponsor must sign on page 2.

• Submit copies of all laboratory tests and additional medical reports with DS-6561.

the DS - 6561 (and supporting documentation) is to scan and email in PDF format to: MEDMR@state.gov. If it is not possible to scan, please fax to Medical Records department FAX: 703-875-4850. If you wish to confirm that your exam forms were received, please email MEDMR@state.gov.

Notes (Describe every abnormality in detail.

Include pertinent item number before each comment.)

VII. Clinical Evaluation Check each item as indicated.

Check "NE" if not evaluated.

Normal Abnormal NE

1. General/Constitution

1. Height 4. Pulse 5. Blood Pressure (sitting) If above 140/85 repeat 3 times and record.

2. Weight lbs. or kgs

in. or cm.

VII: Clinical Evaluation: Newborn exam cannot be accepted if completed before four (4) weeks of age

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)

3. BMI

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

1a. Hematology :

Ages 12 years and older

Hematocrit % or Hemoglobin gms%

WBC /cmm

Platelets

3. Serology Ages 12 years and older

HIV I/II Antibody

2. Chemistry Ages 12 years and older

Fasting Blood Sugar

HgA1C (if indicated)

Creatinine

ALT

1. Hematology:

Ages 1 year to 11 years

Hematocrit % or Hemoglobin gms%

4. Tuberculin Skin Test: Required for ages 1 and over (unless previously positive) 5. 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: mm of induration Date:

Interferon Gamma Release Assay: (may substitute for TST if > 5 y/o or In those with previous BCG)

Results: Date:

If no TB screening performed, explain why:

Previous active tuberculosis

Previous positive TST or IGRA

Previous LTBI treatment

Hx of BcG vaccine

Other:

NoYes

NoYes

NoYes

NoYes

Date:

Date:

Date:

Date:

Results: Date:

DS-6561 Page 4 of 4

Name of Examinee DOB

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

Results:

Date:

OPTIONAL TESTS: The following tests may be performed at the discretion of the Examiner, with patient consent. They are not required for a medical clearance determination. If performed, results may be used in the provision of care to individuals covered under the Department of State Medical Program.

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

7. Blood Type ( if not previously documented) Type: ABO (weak D):

8. G6PD (If not previously documented) for malarial prophylaxis Results: Date:

9. Blood lead level (recommended screening ages 12 months to 5 years) Results: Date:

(Rh) Dµ:

IX. LABORATORY ANALYSIS: All tests are required unless otherwise specified. Test results from previous 12 months are acceptable.

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

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

Telephone NumberExamining Facility

Address

Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Posts

PRE-DEPLOYMENT PHYSICAL EXAM ACKNOWLEDGEMENT FORM

DS-6570

04-2016

Medical Provider Stamp or Print Name

Individual's Name Date of Birth ID

Dear Provider, You have been asked to provide a full medical clearance evaluation for an individual preparing for deployment to . One of the medical clearance requirements is to complete this 2-page form. Page two contains multiple questions the patient is required to answer that will help you in completing a full physical examination on this patient. Please use the information provided by the patient, the findings on your physical exam, and the information about living and working conditions detailed below to determine whether this individual will be able to work and live in a physically challenging and stressful environment.

Please pay special attention to any hematologic, cardiovascular, pulmonary, orthopedic, neurological, endocrine, dermatological, psychological, visual, and auditory conditions which may present a significant risk of substantial harm to the individual or others and/or preclude performing the functional requirements described below in the deployed setting.

Also, the amount of medications being taken and their suitability and availability in a conflict zone must be considered.

The work may require unusual physical exertion under unfavorable conditions including extreme heat, high elevations, extremely dusty conditions and air pollution. The working and living conditions can also include the possibility of dealing with sleep deprivation, emotional stress, and circadian disruption. If maintaining an individual's health requires avoidance of these extremes or exertions, deployment to these areas may not be appropriate.

The individual will be required to wear personal protective equipment (PPE) that may weigh up to 39 pounds (up to 4 pounds for the helmet and up to 35 pounds for the vest). The individual may need to move quickly in such gear and carry additional equipment in an emergency. The individual should be able to perform certain emergency functions to include responding to duck and cover alarms (which could involve quickly seeking cover in a protected bunker), navigating a smoke-filled facility, going up and down stairs wearing PPE, and boarding/ de-boarding helicopters wearing PPE on an independent basis, as assistance may be unavailable in exigent circumstances. Movement in the compound requires maneuvering uneven surfaces and regularly walking up and down several flights of stairs throughout the day.

Transportation may be in off-road vehicles, helicopters, military troop transport aircraft or other military transportation with confined seating. Clearances may be up to 36 inches off the ground with high step rails or ladder-type steps and small entrances when accessing a helicopter. Luggage must be lifted into the helicopter and injuries can occur to persons who are not physically capable of performing these activities.

By signing below, I acknowledge that I have read this form and I can find no apparent medical reason for this person not to be able to live and work in the above described conditions.

PRIVACY ACT NOTICE

AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C.

4084).

PURPOSE: The information solicited on this form will be used to make appropriate medical clearance decisions.

ROUTINE USES: Unless otherwise protected by law or medical privacy regulations, the information solicited on this form may be made available to appropriate agencies, whether Federal, state, local, or foreign, for law enforcement and other authorized administration purposes. The information may also be disclosed pursuant to court order. More information on routine uses can be found in the System of Records Notice State-24, Medical Records.

DISCLOSURE: Providing this information is voluntary; however, failure to provide this information may result in denial of a medical clearance.

OMB APPROVAL NO. 1405-0224

EXPIRES: 02/29/2020

ESTIMATED BURDEN: 30 MINUTES

Medical Provider Signature Date

Instructions: Please answer each of the following questions. Be sure to attach copies of any medical reports that can help clarify a medical condition(s). Failure to provide Medical Clearances with pertinent information will delay processing of the medical clearance decision and post assignment approval. Scan and e-mail the completed 2-page form to MEDMR@state.gov or fax to 202-647-0292.

Yes / No

1. Conditions that prevent the wearing of personal protective equipment, including protective mask, ballistic helmet, body armor, and chemical/biological protective garments, regardless of the nature of the condition that causes the inability?

2. Conditions that prohibit required immunizations (other than smallpox & anthrax per current guidance) or medications (such as anti-malarials, chemical and biological antidotes, and other chemoprophylactic antibiotics)?

3. Any chronic medical condition that requires frequent clinical visits (more than quarterly) or ancillary tests (more than twice/year), that fails to respond to adequate conservative treatment, necessitates significant limitation of physical activity, or constitutes increased risk of illness, injury, or infection?

4. Any unresolved acute illness or injury that would impair one's duty performance during the duration of the deployment?

5. Asthma that has a Forced Expiratory Volume-1 < 50% of predicted despite appropriate therapy, that has required hospitalization in the past 12 months, or that requires daily systemic (not inhaled) steroids?

6. Seizure disorder, either within the last year or currently on anticonvulsant medication for prior seizure disorder/activity?

7. Diabetes mellitus?

8. History of heat stroke?

9. Meniere's disease or other vertiginous/motion sickness disorder?

10. Renalithiasis (Kidney stones), recurrent or currently symptomatic?

11. Obstructive sleep apnea (OSA)?

12. History of clinically diagnosed as having Traumatic Brain Injury (TBI) or concussion?

13. Symptomatic coronary artery disease?

14. Chronic cough or coughing up blood?

15. Myocardial infarction within past two years?

16. Coronary artery bypass graft, coronary artery angioplasty, carotid endarterectomy, other arterial stenting, or aneurysm repair within 2 years?

17. Cardiac dysrhythmias or arrhythmias, either symptomatic or requiring medication, electrophysiologic control, or automatic implantable cardiac defibrillator?

Yes / No

18. Hypertension not controlled with medication or that requires frequent monitoring?

19. Heart failure or history of heart failure?

20. Morbid obesity (BMI > 40) in accordance with National Heart Lung and Blood Institute guidelines?

21. Active or chronic blood-borne diseases (Hepatitis B, Hepatitis C, HIV)?

22. Active tuberculosis?

23. Untreated Latent tuberculosis, or is currently undertreatment?

24. Vision loss?

25. Refractive eye surgery in last year?

26. Currently using ophthalmic steroid drops?

27. Photorefractive keratectomy (PRK) or laser epithelial keratomileusis (LASiK) within the past 6 months?

28. Hearing loss?

29. On-going dental or orthodontic work?

30. On-going cancer therapy?

31. Precancerous lesions that have not been treated?

32. Any medical condition that requires surgery (e.g., unrepaired hernia) or for which surgery has been performed and the patient requires ongoing treatment, rehabilitation or additional surgery to remove devices (e.g., external fixator placement)?

33. Surgery (open or laparoscopic) within past 6 months?

34. Psychotic and Bipolar Disorders?

35. Clinical psychiatric disorders with residual symptoms, or medication side effects?

36. History of the following: psychiatric hospitalization; suicide attempt; substance (medication, illicit drug, alcohol, inhalant, etc.) abuse or treatment for such abuse; PTSD or/TBI?

37. Medications - Blood modifiers?

38. Medications - Antineoplastics (oncologic or nononcologic use)?

39. Medications – Immunosuppressants?

40. Medications - Biologic Response Modifiers (immunomodulators)?

41. Medications – Psychiatric or sleeping aides?

42. Medications – Anticonvulsants?

43. Medications – Pain medications, Opioids, opioid combination drugs?

DS-6570 Page 2 of 2

Patient Printed Name

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection.

You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to Office of Quality Improvement, U.S. Department of State, M/MED/QI, SA-01, Washington DC 20522-0102; medqi@state.gov.

Patient Signature Date

FD-967

Revised

06-12-2003

FEDERAL BUREAU OF INVESTIGATION

NEW AGENT PHYSICAL ACTIVITIES

EMPLOYEE INFORMATION

Name: Date:

AGENT PHYSICAL ACTIVITIES

Please indicate if applicant/trainee can perform the following:

1. Control Techniques: Yes No nmlkj nmlkj

Subject takedown requires grappling in both standing and sitting positions. This drill often includes the fugitive crawl with two trainees restraining a third.

2. Personal Weapon Attacks utilizing confrontation drills:

a.) Full contact boxing Yes No nmlkj nmlkj b.) Kicks Yes No nmlkj nmlkj c.) Fist to elbow strikes Yes No nmlkj nmlkj

3. Officer Survival Techniques: Yes No nmlkj nmlkj

This activity stresses live or die drills, weapons disarming and retention.

4. Carotid Restraint: Yes No nmlkj nmlkj

This technique is used against violently resisting subjects and requires a takedown from the standing position.

5. Handcuffing: Yes No nmlkj nmlkj

Actors or students who pose as arrest subjects sometimes resist strenuously.

6. Break Falls and Shoulder Rolls: Yes No nmlkj nmlkj

7. "O" Course to include:

a.) Climbing and Vaulting Yes No nmlkj nmlkj b.) Jumping from High Obstacles Yes No nmlkj nmlkj c.) Net rope climbing Yes No nmlkj nmlkj

8. Yellow Brick Road: Yes No nmlkj nmlkj

A 7.2 run - includes rope climbs and obstacles both natural and man-made.

9. Firearms: Yes No nmlkj nmlkj

This activity includes long periods of firing from a prone position. Students must also qualify on an obstacle course, which requires shooting from standing, kneeling and prone positions.

PHYSICIAN INFORMATION

Physician's Signature: Date:

Print or Type Name: Telephone Number:

Specialty Board Certified: Yes No nmlkj nmlkj List Specialty:

FD-967 (Revised 06-12-2003) Page 1 of 1 FEDERAL BUREAU OF INVESTIGATION

FD-1065 (Rev. 02-20-2020)

INSTRUCTIONS

Block 1: Name – Use your LEGAL NAME (Last, first, middle initial)

Block 3: Division/Field Office Address – Use your Division of assignment, even if exam is conducted at another location or the Division you are processing from as an applicant.

Block 5: List your current medications, dose and frequency. Include dietary supplements and over-the-counter medications taken regularly, as well as prescribed medications. If none - state "none".

Block 6: List any allergies that you might have. If none - state "none".

Blocks 1-20c: Complete all items 1-20c in entirety. Print and take with you to your examination for physician review.

All "YES" answers must have a detailed description of this history, to include:

a. the date(s) of occurrence,

b. what occurred,

c. treatments and/or surgeries received,

d. the current status of this condition,

e. any related restrictions or limitations, Please use additional pages if necessary to provide requested medical documentation.

Privacy Act Statement: The collection of this information on this form, which is authorized by 5 U.S.C. § 301 and 5 U.S.C. § 3301, is relevant and necessary to provide appropriate medical care and to determine eligibility and/or fitness for duty. Completion of this form is voluntary; however, your failure to supply all the information requested on this form may impede or preclude agency action regarding medical care or continued employment. This information is maintained in your medical file in the FBI Central Records System, Justice/FBI-002, a description of which can be found at http://home.fbinet.fbi/DO/OGC/LTB/PCLU/PrivacyCivil%20Liberties% 20Library/Forms/FBI002.aspx. This information may be disclosed in accordance with the routine uses referenced in this notice.

GINA Notice: Do Not Provide Genetic Information, Including Family Medical History 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 member’s 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. See 29 C.F.R. § 1635.8(b)(1)(i)(B).

http://home.fbinet.fbi/DO/OGC/LTB/PCLU/PrivacyCivil%20Liberties%25

FD-1065 (Rev. 02/20/2020) REPORT OF MEDICAL HISTORY DATE COMPLETED

NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons

1. Examinee Legal Name (Last, First, Middle) 2. Date of Birth

3. Division/Field Office 4. Examining Facility

5. Current Medications, Dose, and Frequency (List all medications to include over the counter and herbals)

NONE (check box) ___

6. Allergies (include insect bites/stings and common foods)

NONE (check box) ___

PAST/CURRENT MEDICAL HISTORY – Check Each Item; if “YES” Explain in the below space. List explanation by condition item.

Item Yes No

7. Do you have any medical condition or physical impairment that could interfere with or otherwise limit your ability in any way to perform your duties fully?

8. Have you ever been admitted or observed overnight in a hospital?

9. Have you had or been advised to have any type of surgery/operation?

10. Have you applied for or are you receiving a pension or compensation for any type of disability?

11. Do you currently have or have you previously had a medical condition that has been evaluated or treated by a clinic, physician, healer, or other practitioner?

12. If you are currently an FBI employee, in the previous two years, have you consulted with or been treated by a clinic, physician, healer, or other practitioner for anything other than minor illness?

13. Have you ever been treated for a mental health condition?

14. Have you ever received mental health counseling of any type?

15. Have you ever been diagnosed with or do you suffer from depression or excessive worry?

16. Have you ever attempted suicide or have considered suicide?

17. Do you use or have you ever used illegal drugs or abused prescription drugs?

18. If you are currently an FBI employee, in the previous two years, have you consulted with or been treated by a clinic, physician, healer, or other practitioner for mental health treatment?

Explanation of all “Yes” findings

19. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purpose of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable by fine and/or imprisonment.

20a. Examinee Legal Name 20b. Examinee Signature 20c. Date

Note: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE “TO BE OPENED BY MEDICAL PERSONNEL ONLY”

FD-1065 (Rev. 02/20/2020) REPORT OF MEDICAL HISTORY DATE COMPLETED

21. SUMMARY AND ELABORATION OF ALL PERTINENT DATA BY EXAMINER

Physician or Nurse Practitioner to comment on all “yes” answers in questions 7-12 and may develop any additional medical history deemed important and record any significant findings here. (See below for Privacy Act Statement and GINA Notice before proceeding).

Privacy Act Statement: The collection of the information on this form, which is authorized by 5 U.S.C. § 301 and 5 U.S.C. § 3301, is relevant and necessary to provide appropriate medical care and to determine eligibility and/or fitness for duty. Completion of this form is voluntary; however, your failure to supply all the information requested on this form may impede or preclude agency action regarding medical care or continued employment. This information is maintained in your medical file in the FBI Central Records System, Justice/FBI-002, a description of which can be found at http://home.fbinet.fbi/DO/OGC/LTB/PCLU/PrivacyCivil%20Liberties% 20Library/Forms/FBI002.aspx. This information may be disclosed in accordance with the routine uses referenced in this notice.

GINA Notice: Do Not Provide Genetic Information, Including Family Medical History 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 member’s 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. See 29 C.F.R. § 1635.8(b)(1)(i)(B).

22. Typed or Printed Name of Physician or Health Care Professional (HCP) 22a. Signature of Physician or HCP 22b. Date

PLEASE USE ADDITIONAL PAGES IF NECESSARY

http://home.fbinet.fbi/DO/OGC/LTB/PCLU/PrivacyCivil%20Liberties

FD-1093 (01-18-2020) REPORT OF MEDICAL EXAMINATION DATE OF EXAM

67# ______________________________________

NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons

1. NAME OF PATIENT – OFFICIAL BUREAU NAME (LAST,FIRST,MIDDLE) 2. DATE OF BIRTH 3. AGE

4. Division 5. Field Office

6. Examining Facility

6a. Street Address of Examining Facility 6b. City 6c. State 6d. Zip Code

7. Rating or Specialty of Examiner 8. Purpose of Examination

9. Sex 10. Race

The remainder of this form is to be completed by Examining Facility Medical staff and Physicians ONLY

11. Height: (in inches) without shoes 12. Weight: (in lbs) 13. Build: Slender Medium Heavy Obese

14. Blood Pressure: Sitting 15. Pulse: Sitting 16. Temperature:

17. Vision DISTANT

WITHOUT CORRECTION

Left: 20/ 18. Vision NEAR

WITHOUT CORRECTION

Left: 20/ Right: 20/ Right: 20/

With Correction (if needed) Left: 20/ With Correction (if needed) Left: 20/ Right:20/ Right: 20/

19. Field of Vision/Strabismus Left: 20.

AUDIOMETER

500 1000 2000 3000 4000 6000 8000 Right: Left

21. Intraocular Tension Left: Right Right:

22. CLINICAL EVALUATION

Check each item in appropriate column, enter “NE” if not evaluated, “NA” if not applicable or “PD” if patient declined

Normal Abnormal Normal Abnormal

A. HEAD, FACE, NECK AND SCALP O. PROSTATE

B. EARS- GENERAL (INTERNAL CANALS)

(Auditory acuity under items 21)

P. TESTICULAR

Q. ANUS AND RECTUM (hemorrhoids, fistulae)

C. Drums (Perforation) R. ENDORCRINE SYSTEM

D. NOSE S. G-U SYSTEM

E. SINUSES

T. UPPER EXTREMITIES (Strength, range of motion)

F. MOUTH AND THROAT U. FEET

G. EYES – GENERAL (Visual acuity under 17 and

18) V. LOWER EXTREMITIES (Except feet)(Strength, range of motion)

H. OPTHALMOSCOPIC W. SPINE, OTHER MUSCULOSKELETAL

I. PUPILS (Equality and reaction) X. IDENTIFYING BODY MARKS, SCARS, TATTOOS

J. OCULAR MOTILITY (Associated parallel movements nystagmus) Y. SKIN, LYMPHATICS

K. LUNGS AND CHEST Z. NEUROLOGIC

L. HEART (Thrust, size, rhythm, sounds) AA. PSYCHIATRIC (Specify any personality deviation)

M. VASCULAR SYSTEM (Varicosities, etc.) BB. BREASTS

N. ABDOMEN AND VISCERA (Include hernia) CC. PELVIC (Female only)

Tuberculin Skin Test (Mantoux):__________________________________________

23. Notes: Describe EVERY abnormality in detail. Enter pertinent item number before each comment. Continue in item 23 and use additional sheets if necessary.

FD-1093 (01-18-2020)

Name: Date of Birth Number of Sheets Attached

23: Notes (continued from page 1) and SIGNIFICANT OR INTERVAL HISTORY

23A. Please comment on the following

Alcohol H istory/Usage: ___________ ___ _____________________ _____________ _____________________ _____________ _____________________ _____________ _______

Tobacco History/Usage: ___________________________________________________________________________________________________________________________

Dietary Habits: __________________________________________________________________________________________________________________________________

Level of Exercise: ________________________________________________________________________________________________________________________________

Travel History: __________________________________________________________________________________________________________________________________

Immunization Status : _____________________________________________________________________________________________________________________________

Considering attached weight table, I consider his/her present weight to be Satisfactory Excessive Deficient Under proper medical supervision, employee should Lose ______lbs Gain ______lbs

24: A. For all Special Agents and Police Officers:

A.1: Does examinee have any defects restricting or prohibiting his/her participation in defensive tactics and dangerous assignments which might entail the practical use of firearms? NO YES A. 2: Does examinee demonstrate uncorrected visual acuity no worse than 20/200 (Snellen) in each eye, with correction to 20/20 in one eye and no worse than 20/40 in the other eye NO YES

B. For employees for positions other than listed in A, above:

B.1: Does examinee demonstrate distant vision no worse than 20/20 in one eye and 20/40 in the other, corrected or uncorrected? NO YES B.2: Does examinee have any defects prohibiting safe operation of motor vehicles (20/40 in one eye and 20/100 in the other eye, corrected or uncorrected)?

NO YES

C. Summary of DEFECTS and DIAGNOSES (list diagnoses with item numbers)

25: RECOMMENDATIONS – FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify)

26: The EMPLOYEE is:

Fit for Duty Not Fit for Duty PENDING FBIHQ Review

26a. If not Fit for Duty, list Disqualifying Defects by Item Number

27. Typed or Printed Name of Physician Signature of Physician Date

28. Typed or Printed Name of Reviewing Officer or Approving Authority Signature of Reviewing Officer or Approving Authority Date

Privacy Act Statement: The collection of the information on this form, which is authorized by 5 U.S.C. § 301 and 5 U.S.C. § 3301, is relevant and necessary to provide appropriate medical care and to determine eligibility and/or fitness for duty. Completion of this form is voluntary; however, your failure to supply all the information requested on this form may impede or preclude agency action regarding medical care or continued employment. This information is maintained in your medical file in the FBI Central Records System, Justice/FBI-002, a description of which can be found at http://home.fbinet.fbi/DO/OGC/LTB/PCLU/PrivacyCivil%20Liberties% 20Library/Forms/FBI002.aspx. This information may be disclosed in accordance

FD-900 (Rev. 9-24-2013)

HAZARDOUS MATERIALS RESPONSE

RESPIRATORY MEDICAL EVALUATION QUESTIONNAIRE

Date __________________

Part A. Section 1, (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print).

1. Name: ____________________________________________________________ 2. Age: ______________

3. Sex: G Male G Female 4. Weight: _________lbs. 5. Height: ____________ ft. ____________in.

6. Your job title: _________________________________________________

7. A phone number where you can be reached by the health care professional who reviews this questionnaire: __________________

8. The best time to phone you at this number: _________________________

9. Has your employer told you how to contact the health care professional who will review this questionnaire? G Yes G No

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

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

b. G Other type (for example, half or full-face piece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

11. Have you worn a respirator? G Yes G No If yes, what type(s): _________________________________________

Part A. Section 2, (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (check appropriate box and if the answer is yes to the following questions, please describe on a separate sheet of paper (indicate Part, Section and question number).

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? G Yes G No

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

a. Seizures (fits): G Yes G No

b. Diabetes (sugar disease): G Yes G No

c. Allergic reactions that interfere with your breathing: G Yes G No

d. Claustrophobia (fear of closed-in places): G Yes G No

e. Trouble smelling odors: G Yes G No

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

a. Asbestosis G Yes G No

b. Asthma G Yes G No

c. Chronic bronchitis G Yes G No

d. Emphysema G Yes G No

e. Pneumonia G Yes G No

f. Tuberculosis G Yes G No

g. Silicosis G Yes G No

h. Pneumothorax (collapsed lung) G Yes G No

i. Lung cancer G Yes G No

j. Broken ribs G Yes G No

k. Any chest injuries or surgeries G Yes G No

l. Any other lung problem that you=ve been told about: G Yes G No

1 - HCPU Medical File 1 - Agent Copy

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath G Yes G No

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline G Yes G No

c. Shortness of breath when walking with other people at an ordinary pace on level ground G Yes G No

d. Have to stop for breath when walking at your own pace on level ground G Yes G No

e. Shortness of breath when washing or dressing yourself G Yes G No

f. Shortness of breath that interferes with your job G Yes G No

g. Coughing that produces phlegm (thick sputum) G Yes G No

h. Coughing that wakes you early in the morning G Yes G No

i. Coughing that occurs mostly when you are lying down G Yes G No

j. Coughing up blood in the last month G Yes G No

k. Wheezing G Yes G No

l. Wheezing that interferes with your job G Yes G No

m. Chest pain when you breathe deeply G Yes G No

n. Any other symptoms that you think may be related to lung problems G Yes G No

5. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack G Yes G No

b. Stroke G Yes G No

c. Angina G Yes G No

d. Heart failure G Yes G No

e. Swelling in your legs or feet (not caused by walking) G Yes G No

f. Heart arrhythmia (heart beating irregularly) G Yes G No

g. High blood pressure G Yes G No

h. Any other heart problem that you=ve been told about G Yes G No

6. Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest G Yes G No

b. Pain or tightness in your chest during physical activity G Yes G No

c. Pain or tightness in your chest that interferes with your job G Yes G No

d. In the past two years, have you noticed your heart skipping or missing a beat G Yes G No

e. Heartburn or indigestion that is not related to eating G Yes G No

f. Any other symptoms that you think may be related to heart or circulation problems G Yes G No

7. Do you currently take medication for any of the following problems?

a. Breathing or lung problems G Yes G No

b. Heart trouble G Yes G No

c. Blood pressure G Yes G No

d. Seizures (fits) G Yes G No

8. If you=ve used a respirator, have ever had any of the following problems? (If you=ve never used a respirator, check the following space and go to question 9:)

a. Eye irritation G Yes G No

b. Skin allergies or rashes G Yes G No

c. Anxiety G Yes G No

d. General weakness or fatigue G Yes G No

e. Any other problem that interferes with your use of a respirator G Yes G No

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? G Yes G No

Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-face piece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

10. Have you ever lost vision in either eye (temporarily or permanently)? G Yes G No

11. Do you currently have any of the following vision problems?

a. Wear contact lenses G Yes G No

b. Wear glasses G Yes G No

c. Color blind G Yes G No

d. Any other eye or vision problem G Yes G No

12. Have you ever had an injury to your ears, including a broken ear drum? G Yes G No

13. Do you currently have any of the following hearing problems?

a. Difficulty hearing G Yes G No

b. Wear a hearing aid G Yes G No

c. Any other hearing or ear problem G Yes G No

14. Have you ever had a back injury? G Yes G No

15. Do you currently have any of the following musculoskeletal problems?

a. Weakness in any of your arms, hands, legs, or feet G Yes G No

b. Back pain G Yes G No

c. Difficulty fully moving your arms and legs G Yes G No

d. Pain or stiffness when you lean forward or backward at the waist G Yes G No

e. Difficulty fully moving your head up or down G Yes G No

f. Difficulty fully moving your head side to side G Yes G No

g. Difficulty bending at your knees G Yes G No

h. Difficulty squatting to the ground G Yes G No

i. Climbing a flight of stairs or a ladder carrying more that 25 lbs. G Yes G No

j. Any other muscle or skeletal problem that interferes with using a respirator G Yes G No

Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen? G Yes G No If yes, do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you=re working under these conditions? G Yes G No

2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals? G Yes G No If yes, name the chemicals if you know them: ____________________________________________________________________________________________

3. Have you ever worked with any of the materials, or under any of the conditions, listed below:

a. Asbestos G Yes G No

b. Silica (e.g., in sandblasting) G Yes G No

c. Tungsten/cobalt (e.g., grinding or welding this material) G Yes G No

d. Beryllium G Yes G No

e. Aluminum G Yes G No

f. Coal (for example, mining) G Yes G No

g. Iron G Yes G No

h. Tin G Yes G No

i. Dusty environments G Yes G No

j. Any other hazardous exposures G Yes G No

If yes, describe these exposures: ________________________________________________________________________________

4. List any second jobs or side businesses you have: ______________________________________________________________

5. List your previous occupations: ____________________________________________________________________________

6. List your current and previous hobbies: _____________________________________________________________________

7. Have you been in the military services? G Yes G No

If yes, were you exposed to biological or chemical agents (either in training or combat)? G Yes G No

8. Have you ever worked on a HazMat team? G Yes G No

9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications)? G Yes G No If yes, name the medications if you know them: ____________________________________________________________________

10. Will you be using any of the following items with your respirator(s)?

a. HEPA Filters G Yes G No

b. Canisters (for example, gas masks) G Yes G No

c. Cartridges G Yes G No

11. How often are you expected to use the respirator (check the box for all answers that apply to you)?

a. Escape only (no rescue) G Yes G No

b. Emergency rescue only G Yes G No

c. Less than 5 hours per week G Yes G No

d. Less than 2 hours per day G Yes G No

e. 2 to 4 hours per day G Yes G No

f. Over 4 hours per day G Yes G No

12. During the period you are using the respirator(s), is your work effort?

a. Light (less than 200 kcal per hour) G Yes G No

If yes, how long does this period last during the average shift _________ hrs. __________ mins.

Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.

b. Moderate (200 to 350 kcal per hour) G Yes G No

If yes, how long does this period last during the average shift ? _________ hrs. __________ mins.

Examples of moderate work are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.

c. Heavy (above 350 kcal per hour) G Yes G No

If yes, how long does this period last during the average shift _________ hrs. __________ mins

Example of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph;…