Attachment 4 - ENG Form 6227- Diver Medical Instructions and Authorization.pdf

ENG FORM 6227, JUN 2021 Page of

U.S. Army Corps of Engineers (USACE)

DIVER MEDICAL INSTRUCTIONS AND AUTHORIZATION

For use of this form, see ER 385-1-86; the proponent agency is CESO.

DO NOT include medical information on this document - Document in accordance with Privacy Act

Last Name First Name Middle Name

Home District Duty Station Location

Type of Examination - Cross out non-applicable sections

Diving Physician Instructions: If you have any reservation about the fitness of the candidate/diver to perform rigorous work underwater at depths of up to 110 FSW, please order the medically appropriate tests and specialist consultations to provide data for your clinical fitness for duty decision.

Initial Periodic (all ages)

If New, or Break In Service Complete Sections 1 and 2

Annually Complete Sections 1

Report of Physical Examination: Please complete a vital sign, cardiovascular, neurology, vision, musculoskeletal, EENT, behavioral, GI, and wellness examination.

APPLICANT CERTIFICATION:

I will notify my Diving Physician of any changes to my health status that are frequent or last over 8 days and will notify my District Diving Coordinator of temporary conditions (<7 days) that require me to be unfit for diving

SECTION I - All INITIAL AND PERIODIC EXAMINATIONS (DO NOT INCLUDE REPORT RESULTS)

Report of Medical History

Body Mass Index >30 or Framingham Risk category of Moderately Above-Average Risk or High-Risk - complete cardiac treadmill, a nuclear, or echocardiographic stress test to 13 METs using Bruce protocol. A stress test is valid for 5-years unless there is a change in the cardiac status.

Lab: Complete Blood Count (CBC)

Lab: Complete Chemistry (CMP) with HbA1C

Lab: Complete urinalysis

Lab: Lipid screening

Spirometry or Pulmonary Function Test

Audiogram

12-Lead resting EKG

Sickle Cell screening (only once)

SECTION II - All INITIAL EXAMINATIONS (must include these additional test results)

Chest x-ray report

Applicant Name Date Applicant Signature

DIVING PHYSICIAN: I certify I am a Licensed Physician and:

Completed USN or UHMS Diving Medical Officer Course

Current FAA Aeromedical Examiner with hyperbaric medicine experience

I have reviewed the attached medical information and have found the applicant named above to be:

Medically cleared for full working diving duty

NOT Medically cleared for diving duty. Please specify the reason(s) in a sealed medical note to the employee.

DO NOT PROVIDE THE MEDICAL NOTE TO YOUR DISTRICT DIVING COORDINATOR

Diving Physician Name (Required) Date Diving Physician Signature

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority ER 385-1-86, EM 385-1-1, and OSHA subpart T.

Principal Purpose To communicate the authorization of divers for duty.

Routine Uses Information will be shared with the Division/District/Center/Lab Diving Coordinator.

Disclosure Voluntary, however an incomplete form will prohibit the employee from diving.

ENG FORM 6227, JUN 2021 Page of

U.S. ARMY CORPS OF ENGINEERS

WORKING DIVER

MEDICAL STANDARDS SUMMARY

Diving Physician: Thank you for the examination and medical recommendation for fitness of the U.S. Army Corps of Engineers employee to successfully work in a working dive environment. This is NOT A SCUBA DIVER examination but an examination to assess the fitness of the candidate to dive using a hardhat surface supplied air system and perform rigorous work underwater in cold temperatures. If you have any reservations about the fitness of the candidate to perform rigorous work underwater, please order the medically appropriate tests and specialist consultations to provide data for your fitness for duty decision.

Medical Risk to Working Diving Operations:

Certain conditions are considered to potentially disqualify working diving based on the excessive risk to the diver, the team, and/or the mission.

Included here are the general medical conditions that affect the ability to dive in a safe manner. The list is not intended to be all-inclusive, and failure to specify a particular condition under this section does not imply the condition is compatible with safe diving. This is a summary, if you wish to have a copy of the full medical standards or have a question email hqmedical@usace.army.mil.

Functional requirements for working diving:

1. Consideration shall be given to the individual's fitness for duty in terms of the function required prior to the diving operations, during the diving operations, and after the diving operations.

2. The individual must be able to perform all functions required by a working diver, to include:

a. the ability to use all fine motor skills required for small/delicate tool work;

b. the ability to use all gross motor skills required for large/heavy took work;

c. the ability to communicate effectively using hand signals/rope signals/verbal commands;

d. the ability to safely wear all diving garments/gear for hardhat diving operations;

e. the ability to safely and quickly swim 550 yards uninterrupted within 15 minutes;

f. the ability to safely work in no-light/low-light conditions and confined spaces;

g. the ability to have equilibrium sufficient for safe walking, swimming, and working diving;

h; the ability to withstand hyperbaric environment (not prone to barotrauma of ear, lung, GI);

i; the ability to withstand the decompression environment (not prone to gas embolism/DCS);

j; the ability to have full consciousness at all times (not prone to loss of consciousness);

k; the ability to be in full health (not having diseases that diving could worsen);

l; the ability to be mentally resilient, highly adaptable to change, and calm under pressure.

General Medical Conditions that warrant disqualification:

1. Any chronic or acute medical condition or medication that treats a medical condition, which affects the physical performance, adaptability to the depth environment, sound judgment, is progressive in its course, is unpredictable, or may be worsened by the individual's dive activities.

2. Any condition, which poses a potential threat to the health and safety of the individual, their dive team, or the mission.

3. Any condition, which could potentially require any medical management or medical treatment that is beyond the capabilities of a person trained in basic first aid.

USACE EMPLOYEE INSTRUCTIONS:

Medically Cleared: I will retain a copy of this document and provide it to my Designated Diving Coordinator.

Medically NOT Cleared: I may submit a letter to request an exception to policy in writing within 30 days of the determination by the Diving Physician to USACE Headquarters at hqmedical@usace.army.mil mailto:hqmedical@usace.army.mil?subject=Eng%20Form%206227 mailto:hqmedical@usace.army.mil?subject=Eng%20Form%206227

ENG FORM 6227, JUN 2021

Page of

ENG FORM 6227, JUN 2021

Page of U.S. Army Corps of Engineers (USACE)

DIVER MEDICAL INSTRUCTIONS AND AUTHORIZATION

For use of this form, see ER 385-1-86; the proponent agency is CESO.

DO NOT include medical information on this document - Document in accordance with Privacy Act Type of Examination - Cross out non-applicable sections Diving Physician Instructions: If you have any reservation about the fitness of the candidate/diver to perform rigorous work underwater at depths of up to 110 FSW, please order the medically appropriate tests and specialist consultations to provide data for your clinical fitness for duty decision.

If New, or Break In Service Complete Sections 1 and 2 Annually Complete Sections 1 Report of Physical Examination: Please complete a vital sign, cardiovascular, neurology, vision, musculoskeletal, EENT, behavioral, GI, and wellness examination.

APPLICANT CERTIFICATION:

I will notify my Diving Physician of any changes to my health status that are frequent or last over 8 days and will notify my District Diving Coordinator of temporary conditions (<7 days) that require me to be unfit for diving SECTION I - All INITIAL AND PERIODIC EXAMINATIONS (DO NOT INCLUDE REPORT RESULTS) Report of Medical History Body Mass Index >30 or Framingham Risk category of Moderately Above-Average Risk or High-Risk - complete cardiac treadmill, a nuclear, or echocardiographic stress test to 13 METs using Bruce protocol. A stress test is valid for 5-years unless there is a change in the cardiac status.

Lab: Complete Blood Count (CBC) Lab: Complete Chemistry (CMP) with HbA1C Lab: Complete urinalysis Lab: Lipid screening Spirometry or Pulmonary Function Test Audiogram 12-Lead resting EKG Sickle Cell screening (only once) SECTION II - All INITIAL EXAMINATIONS (must include these additional test results) Chest x-ray report DIVING PHYSICIAN: I certify I am a Licensed Physician and:

I have reviewed the attached medical information and have found the applicant named above to be:

DO NOT PROVIDE THE MEDICAL NOTE TO YOUR DISTRICT DIVING COORDINATOR

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority ER 385-1-86, EM 385-1-1, and OSHA subpart T.Principal Purpose To communicate the authorization of divers for duty.Routine Uses Information will be shared with the Division/District/Center/Lab Diving Coordinator.Disclosure Voluntary, however an incomplete form will prohibit the employee from diving.

U.S. ARMY CORPS OF ENGINEERS

WORKING DIVER

MEDICAL STANDARDS SUMMARY

Diving Physician: Thank you for the examination and medical recommendation for fitness of the U.S. Army Corps of Engineers employee to successfully work in a working dive environment. This is NOT A SCUBA DIVER examination but an examination to assess the fitness of the candidate to dive using a hardhat surface supplied air system and perform rigorous work underwater in cold temperatures. If you have any reservations about the fitness of the candidate to perform rigorous work underwater, please order the medically appropriate tests and specialist consultations to provide data for your fitness for duty decision.

Medical Risk to Working Diving Operations:

Certain conditions are considered to potentially disqualify working diving based on the excessive risk to the diver, the team, and/or the mission. Included here are the general medical conditions that affect the ability to dive in a safe manner. The list is not intended to be all-inclusive, and failure to specify a particular condition under this section does not imply the condition is compatible with safe diving. This is a summary, if you wish to have a copy of the full medical standards or have a question email hqmedical@usace.army.mil.

Functional requirements for working diving:

1. Consideration shall be given to the individual's fitness for duty in terms of the function required prior to the diving operations, during the diving operations, and after the diving operations.

2. The individual must be able to perform all functions required by a working diver, to include:

a. the ability to use all fine motor skills required for small/delicate tool work;

b. the ability to use all gross motor skills required for large/heavy took work;

c. the ability to communicate effectively using hand signals/rope signals/verbal commands;

d. the ability to safely wear all diving garments/gear for hardhat diving operations;

e. the ability to safely and quickly swim 550 yards uninterrupted within 15 minutes;

f. the ability to safely work in no-light/low-light conditions and confined spaces;

g. the ability to have equilibrium sufficient for safe walking, swimming, and working diving;

h; the ability to withstand hyperbaric environment (not prone to barotrauma of ear, lung, GI);

i; the ability to withstand the decompression environment (not prone to gas embolism/DCS);

j; the ability to have full consciousness at all times (not prone to loss of consciousness);

k; the ability to be in full health (not having diseases that diving could worsen);

l; the ability to be mentally resilient, highly adaptable to change, and calm under pressure.

General Medical Conditions that warrant disqualification:

1. Any chronic or acute medical condition or medication that treats a medical condition, which affects the physical performance, adaptability to the depth environment, sound judgment, is progressive in its course, is unpredictable, or may be worsened by the individual's dive activities.

2. Any condition, which poses a potential threat to the health and safety of the individual, their dive team, or the mission.

3. Any condition, which could potentially require any medical management or medical treatment that is beyond the capabilities of a person trained in basic first aid.

USACE EMPLOYEE INSTRUCTIONS:

Medically Cleared: I will retain a copy of this document and provide it to my Designated Diving Coordinator.

Medically NOT Cleared: I may submit a letter to request an exception to policy in writing within 30 days of the determination by the Diving Physician to USACE Headquarters at hqmedical@usace.army.mil 1.0 darwin.chen@usace.army.mil 2021-02-08 Forms Design Team Darwin Chen 2021-06-30

DIVER MEDICAL INSTRUCTIONS AND AUTHORIZATION

DIVER MEDICAL INSTRUCTIONS AND AUTHORIZATION