340_Medical_Order_Final_Version_021113_krj_(2).pdf

DISTRIBUTION: INITIATED BY:

Available Online: http://www.int.wapa.gov/Directives/alphadir.htm CSO, Safety and Occupational Health Office

U.S. Department of Energy

SUBJECT: FEDERAL EMPLOYEE OCCUPATIONAL MEDICAL PROGRAM

1. OBJECTIVES. This Order establishes requirements for the Western Area Power

Administration (Western) Federal Employee Occupational Medical Program

(FEOMP).

2. CANCELLATION. WAPA Order (O) 340.1C, Federal Employee Occupational

Medical Program, dated 12-02-09.

3. APPLICABILITY. The provisions of this Order apply to all elements of Western.

4. DEFINITIONS.

Adverse Environmental Conditions. Those environmental factors which present a.

a risk of injury, sickness, or impaired health (e.g., chemicals, bacteria, temperature, radiation, noise).

Arduous Duties. Positions that are dangerous or physically demanding to such a b.

degree that an incumbent’s medical condition is necessarily an important consideration in determining ability to perform safely and efficiently.

Audiogram. A graphic representation on which a person’s ability to hear different c.

pitches (frequencies) at different volumes (intensities) of sound is recorded.

Hazardous Duties. Those duties in which adverse environmental conditions d.

could result in undesired physical or medical conditions and/or those duties in which certain physical or medical conditions, either pre-existing, slowly developing, or suddenly occurring, can cause an unacceptable risk of injury or illness to the employee or others.

Western Medical Advisor. A medical physician qualified in occupational medicine e.

and health whose services are secured by a contract or interagency agreement with Western.

Commercial Driver’s License (CDL) Medical Examination. An examination to f.

determine a driver’s physical qualification to operate a commercial motor vehicle

ORDER

DATE: XX-XX-XX

WAPA O 340.1D

WAPA O 340.1D 2

in interstate commerce according to the requirements in Title 49, Code of Federal Regulations (CFR) § 391.41-49, Transportation, dated 01-03-12.

Medical Examinations. g.

(1) Pre-employment/Exit. A medical examination is required to determine a potential employee’s or current employee’s medical qualification and health status prior to any exposures associated with a job, to determine the individual’s continued physical capability to perform assigned tasks safely, and to determine the employee’s medical condition upon leaving the Agency.

(2) Annual. A medical examination is required on a recurring basis for employees in specific occupations. See Attachment 2.

(3) Fitness-for-Duty. A medical examination is required whenever there is a direct question about an employee’s continued capacity to meet the physical or medical requirements of a position. See Attachment 2.

(4) Return to Work. A medical examination is required when there is a question about an employee’s ability to return from an absence for medical or health reasons.

(5) Job Change. An examination for employees who change from or to a job covered by Attachment 2, to include retiring or separating from a position.

(6) Optional Wellness. A medical examination at the election of the employee, performed by the employee’s personal physician. Available to all Federal employees following the criteria of this Order, as stated in paragraph 7e(1).

(7) Optional Wellness Eye. An eye examination at the election of the employee, performed by the employee’s optometrist or ophthalmologist. Available to all Federal employees following the criteria of this Order as stated in paragraph 7e(2).

Medical Examination Form. The U.S. Office of Personnel Management (OPM) h.

Optional Form 178 (OF 178), (Attachment 6) shall be used for all required examinations.

5. POLICY.

Failure to meet a properly established physical requirement under this Order a.

means that the individual is not qualified for the position unless a waiver or reasonable accommodation is granted. The agency must waive a physical requirement when there is sufficient evidence that an applicant or employee, with or without reasonable accommodation, can perform the essential duties of the position without endangering the health and safety of the individual or others.

kjensen Typewritten Text kjensen Typewritten Text

WAPA O 340.1D 3

All physical requirements will be documented in the position description and b.

clearly supported by the actual duties of the position without regard to age, gender, race, color, national origin, religion, disability, genetic information or any other factor that is not job-related.

When Western orders a medical examination in accordance with the c.

requirements of this Order, the Human Resources (HR) Office (for pre-employment applicant examinations) and the Regional Safety Office (for incumbent employee examinations) shall inform the employee in writing of the reason(s) for ordering the examination and the consequences of failure to cooperate.

Occupational medical examinations required by Western (including d.

pre-employment/exit examinations) shall be provided at no cost to the applicant or incumbent employee by a Western-approved physician or practitioner.

Employees shall be reimbursed for the optional wellness and eye examinations e.

in accordance with paragraph 7e(3) of this Order.

6. RESPONSIBILITIES.

Corporate Services Office (CSO) of Safety and Occupational Health (SOH). a.

(1) Establishes and administers the provisions of this Order.

(2) Evaluates the performance of Western’s FEOMP.

(3) Coordinates with the Manager, Office of Economic Impact and Diversity

(OEID), to ensure the environment is free of discrimination for those employees requiring reasonable accommodations.

CSO Office of HR. b.

(1) Establishes procedures to conduct pre-employment examinations of individuals being placed into the occupations listed in Attachment 2.

(2) Coordinates with Regional Human Resources Advisors (HRA) and Colorado River Storage Project (CRSP) Management Center (MC) HR Point of Contact (POC) on medical determinations.

(3) Maintains and manages employee medical records in accordance with applicable regulations.

WAPA O 340.1D 4

Regional and CSO Managers and the CRSP MC Manager. Ensures the c.

provisions of this Order are implemented in their respective offices.

Regional HRA, CRSP MC, HRA POC, and Regional Safety and Security d.

Manager (RSSM).

(1) Provides assistance to managers, supervisors, and employees on matters dealing with this Order.

(2) Coordinates with the Manager, OEID, to ensure the environment is free of discrimination for those employees requiring reasonable accommodations.

(3) Regional HRA and the CRSP HR POC are delegated the authority to supplement Attachment 2 in cases where an employee in a position not listed may be exposed to harsh situations or activities on a recurring basis.

Inform CSO HR, CSO SOH Manager and the applicable Union of any changes to Attachment 2.

Manager, OEID. Coordinates with CSO HR Office, SOH Office, and Regional e.

HRA and RSSM to ensure the workplace is free of discrimination.

Western Medical Advisor. f.

(1) Recommends requirements for employee medical examinations based on job duties, physical work environment, and physical requirements for specific positions/occupations.

(2) Recommends physicians and other medical providers who are qualified in occupational medicine.

(3) Monitors employee occupational medical examinations to ensure that Western’s requirements are satisfied.

(4) Reviews and issues clearance for duty letters, fitness-for-duty physicals and return to work physicals that have been performed in the regions.

(5) Provides medical consultations which includes requesting or verifying the need for any follow up testing as a result of a required medical examination.

(6) Provides oversight for a system of health care records that assures security and confidentiality.

(7) Does not have to be physically located within Western’s regions. May work with local occupational physicians within Western’s regions or other physicians with specific expertise.

WAPA O 340.1D 5

(8) Does not perform routine medical examinations.

(9) Reviews Western’s Medical Order and provides recommendations for revisions based on medical expertise.

7. REQUIREMENTS.

Health Services Personnel. Health services shall, to the extent possible, be a.

provided under the direction of physicians qualified in occupational medicine and assisted by licensed nurses or physicians’ assistants qualified in occupational nursing.

Pre-employment Medical Examination. After a conditional offer of employment b.

has been made by the HRA for a position where hazardous/arduous duties or physical requirements have been identified and recorded, see Attachment 2, the conditional employee shall have a medical examination to determine the individual’s medical qualification for the position. The medical examinations shall be provided at no cost to the applicant by a Western-approved medical provider.

The standard format for pre-employment examinations is provided in Attachment 3.

Occupational Health Monitoring. The CSO SOH Office shall, with the assistance c.

of the Medical Advisor, establish an occupational health monitoring program for those employees in positions with identified health risk factors or physical requirements listed in Attachment 2. Medical examinations required by this program and conducted by a Western-approved occupational health medical provider shall be at no cost to the employee. Required medical examinations shall be conducted or reviewed by an occupational medical physician. The standard format for required medical examinations is provided in Attachment 3.

Required Medical Examinations. d.

(1) Attachment 2 lists the positions which have been designated as having adverse environmental conditions, hazardous/arduous duties or physical requirements. Incumbents of these positions shall have periodic medical examinations to ensure that they are medically qualified to perform their work.

(2) Per the requirements of some positions, the employee will receive a CDL medical examination when operating vehicles which require a CDL as defined in 49 CFR § 383, Subpart F, Vehicle Groups and Endorsements, dated10-01-12.

(3) A synopsis of the duties and the required medical examinations shall be sent to the examining physician. Any diagnostic test or special examination

WAPA O 340.1D 6

deemed necessary by the physician, but not specifically listed in the OF 178 (Attachment 6) will be referred to the Western Medical Advisor.

(4) The examining physician will be instructed to discuss the findings with the employee and submit a written report to the employee. A completed OF 178 containing only the job-related portions of the examination shall then be placed in an envelope marked “Confidential-Medical” and submitted to the appropriate local office (Safety Office or HR office). The employee will be required to sign and date a release form (see Attachment 9 for sample format) prior to the examination.

(5) The Safety Office or HR office in consultation with the Western Medical

Advisor will advise the employee and his or her supervisor in writing of any examination results that raise a question as to the employee’s ability to perform the essential functions of his or her position. The employee and supervisor shall be advised in writing after the agency has received written notice from the physician releasing the employee from all work restrictions.

When requested by the employee, CSO HR will provide a copy of his or her medical records to the employee.

(6) If the medical evaluation results in a determination that the employee is unable to perform the essential functions of his or her position, the Western Medical Advisor and HRA will work with the employee and supervisor to discuss possible options. Options may include: cooperation with the employee on rehabilitation efforts; reassignment to a position within the employee’s medical capabilities; disability retirement; reasonable accommodations using Western’s Reasonable Accommodation Procedures Manual; or separation. In taking any of these actions, the employee’s rights under applicable laws, regulations, and collective bargaining agreements must be protected, and the employee will be counseled concerning the alternatives available. The Regional Safety Office and the supervisor will be notified of accommodations, limitations and/or restrictions.

(7) The employee’s Regional Safety Office will be notified in writing in any of the following situations:

(a) Work limitations (light duty), medical restriction, and/or lost workdays.

(b) Standard threshold shifts (STS) of 10 decibel (dB) or more in the 2000, 3000, or 4000 hertz (Hz) range on the audiogram.

(c) Blood test results that show abnormal chemistry levels when a blood test was requested due to possible chemical or pesticide exposure.

(d) Respirator medical clearance (Pulmonary Function Test) stating employee’s fitness to wear a respirator.

WAPA O 340.1D 7

(e) Eye sight restrictions that would restrict or make an employee ineligible to drive a government vehicle or perform certain duties.

(f) Prescription medications voluntarily identified by the employee during the examination, that are being taken, that could affect the employee’s ability to safely perform their job.

(8) Electrical shocks caused by induced voltages or known energized circuits/conductors shall be evaluated by a medical provider.

Optional Wellness and Eye Examinations. e.

(1) Optional Wellness Examinations. Employees not covered by Attachment 2 may be reimbursed up to $75 for an optional wellness examination by a physician of the employee’s choosing in accordance with paragraph 7e(3) below. All employees covered by Attachment 2 may be reimbursed up to $75 for optional tests (e.g., Prostate Specific Antigen, Mammogram, Hemoccult, pap smear) that are not included in required physical protocols.

Optional tests may be performed by a physician of the employee’s choosing in accordance with paragraph 7e(3) below. The frequency for reimbursement will be based on the following:

Employee’s age 39 and under – Every 3 years

Employee’s age 40 and over – Every 2 years

(2) Optional Wellness Eye Examinations. Employees may be reimbursed up to

$100 for an optional routine eye examination by an optometrist or ophthalmologist of the employee’s choosing in accordance with paragraph 7e(3) below. The frequency for reimbursement will be based on the following:

Employee’s age 39 and under – Every 4 years

Employee’s age 40 and over – Every 2 years

(3) Reimbursement. Reimbursement for wellness and eye examinations shall be made to the employee, by direct deposit upon submission of the following information to their local Finance office:

(a) A completed WAPA F 2200.57, Claim For Reimbursement for

Expenditures on Official Business, to include:

1 Amount of expense not covered by insurance and claimed for reimbursement (for example co-pays).

WAPA O 340.1D 8

2 A statement certifying that reimbursement for a physical or eye examination has not been received within the allotted time frame.

3 A valid project, object class, and task number to charge costs. A valid work order is the work order where the employee’s time is usually charged, unless a general reimbursement work order is established individually within a Region, or the CSO.

4 The employee’s signature and supervisory approval.

(b) The original of the employee’s health insurance statement or billing statement showing a medical or eye examination was provided, and the amount that was paid by the employee.

(4) Aside from the medical and eye examination, any follow-up tests deemed necessary due to specific health factors of the employee that are not directly related to his or her employment will be the responsibility of the employee.

Job Change Medical Examination. f.

Employees who change from or to a job covered by Attachment 2, to include retiring or separating from a position, shall have their health status and physical fitness reviewed by the medical advisor with emphasis on the effects of the position vacated and the health and physical factors that relate to the new job tasks and demands. If the review indicates a medical examination is necessary (e.g., a pre-employment medical examination), it shall be provided at no cost to the employee.

Return to Work Examination. g.

A medical examination may be required when an employee who occupies a position listed in Attachment 2 of this Order is absent from work for an extended period of time and is under the care of a physician or for other medical or health reasons. The decision to require a medical examination will be made by the first-line supervisor with the concurrence of the servicing HRA. The examination will be:

(1) Sufficient to ensure that the employee’s return to work/remaining at work will be without undue risk of injury or illness to the employee or others.

(2) At no expense to the employee if performed by a Western-approved physician.

(3) At the employee’s expense if performed by an unapproved medical provider.

Absent compelling evidence to the contrary, if the employee’s personal physician certifies that the employee is able to return to/remain at work without undue risk

WAPA O 340.1D 9

of injury or illness to the employee or others, Western will accept that certification and the employee will be returned to work. If, based on the Medical Advisor’s opinion, compelling evidence is available that indicates that the employee may not be able to return to/remain at work, Western may request at no cost to the employee a second opinion from a board certified physician selected by Western.

Fitness-for-Duty Examination. A medical examination may be required whenever h.

there is a direct question about the continued capacity to meet the physical requirements of a position for an employee who occupies a position listed in Attachment 2 of this Order. The decision to require a medical examination will be made by the first-line supervisor with the concurrence of the servicing HRA. For this examination the Certificate of Medical Examination OF 178, Attachment 6, will be used. The examination will be:

(a) Sufficient to ensure that the employee will be able to work without undue risk of injury or illness to the employee or others.

(b) At no expense to the employee.

(c) Performed by a Western-approved physician.

Health Maintenance Services. If available, health maintenance services may be i.

provided at no cost to the employee. Types of services include:

(a) Administration of vaccines (e.g., flu shots, and tetanus shots).

(b) Treatment prescribed by a physician providing medical care in occupational injury or illness cases accepted in accordance with the provisions set forth by the Office of Workers’ Compensation Program (OWCP) under the Federal Employees Compensation Act (FECA).

(c) Tests and immunization for specific diseases shall be provided as necessary by health services personnel.

(d) Health education and counseling, including utilization of Employee Assistance Program services (EAP).

Employee Medical Records. The CSO HR Office will maintain and manage j.

employee medical records in accordance with applicable regulations.

WAPA O 340.1D 10

Costs. The cost of examinations and services provided under this Order will be k.

paid out of the operating funds of the Western office to which the employee/applicant is or will be assigned. The cost of optional wellness and eye examinations will be paid for initially by the employee with reimbursement by Western in accordance with paragraph 7e(3) above. Payment of overtime or other premium pay will be made in accordance with the provisions of the applicable collective bargaining agreement and pay regulations.

Use of Official Time. l.

(1) Employees are considered in a duty status while undergoing a required medical examination and the time necessary to travel to and from the medical facility.

(2) Optional wellness and eye examinations received by an employee under paragraph 7e above must be completed during an approved absence from duty. An employee is allowed up to 4 hours each leave year; excused absence (administrative leave) to participate in optional medical evaluations.

8. CONTACTS. Questions concerning this Order should be addressed to the CSO

SOH Office at (720) 962-7295 or Regional Safety Office.

Anita J. Decker Acting Administrator

WAPA O 340.1D Attachments

TABLE OF CONTENTS

ATTACHMENTS

ATTACHMENT 1 REFERENCES

ATTACHMENT 2 POSITIONS WITH PHYSICAL REQUIREMENTS AND

ENVIRONMENTAL FACTORS

ATTACHMENT 3 EXAMINATION REQUIREMENTS FOR PRE-EMPLOYMENT

AND ANNUAL PHYSICALS

ATTACHMENT 4 SUGGESTED MEMORANDUM FOR NOTIFICATION OF

ANNUAL MEDICAL EXAMINATIONS

ATTACHMENT 5 INSTRUCTIONS TO THE EXAMINING PHYSICIAN

ATTACHMENT 6 CERTIFICATE OF MEDICAL EXAMINATION

ATTACHMENT 7 RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE

ATTACHMENT 8 AUDIOMETRY QUESTIONNAIRE/TEST

ATTACHMENT 9 SAMPLE MEDICAL RELEASE FORM

ATTACHMENT 10 CLAIM FOR REIMBURSEMENT

LINKS

PRE-EMPLOYMENT/EXIT

ANNUAL/PERIODIC

FITNESS-FOR-DUTY

WAPA O 340.1D Attachment 1 XX-XX-XX Page 1 of 2

REFERENCES

5 U.S.C. § 7901 (2012), Health Service Programs, authorizes Heads of Departments and agencies to establish Federal employee health service programs by contract or otherwise, following consultations with the Public Health Service.

5 CFR Part 293, Subpart E, Employee Medical File System Records, dated 01-01-12, provides authorities and procedures for agencies to require or request medical information relevant to taking a personnel management action; maintain medical documentation and records; protect medical records; and to establish physical requirements for positions.

5 CFR Part 339, Medical Qualification Determinations, dated 01-01-12, provides the basis for the establishment of medical qualification standards and programs, and physical requirements for Federal civilian positions.

49 CFR Part 383, Subpart F, Commercial Driver’s License Standards, Requirements, and Penalties, dated 10-11-12, defines commercial motor vehicle groups which require an operator to obtain a commercial driver’s license.

49 CFR Part 391, Subpart E, Physical Qualifications and Examinations, dated 10-11-12, defines the medical qualification requirements to determine if an operator is physically qualified to drive a commercial motor vehicle and hold a commercial driver’s license.

29 CFR § 1614.203, Rehabilitation Act, dated 07-01-12, defines disabilities and explains agency requirements for hiring and accommodating persons with disabilities to ensure employees and applicants are not discriminated against on the basis of physical or mental disability. Refer to Title 9 U.S.C. 701, et seq.

29 CFR Part 1630, Regulations to Implement the Equal Employment Provisions of the Americans with Disabilities Act, dated 07-01-12, implements the American with Disabilities Act as amended 2008 and establishes accommodation requirements for persons with disabilities.

29 CFR 1635, Regulations Under the Genetic Information Nondiscrimination Act of 2008, dated 11-09-10, protects job applicants, current and former employees, and apprentices and trainees from discrimination based on their genetic information.

29 CFR Part 1910 and 1960, Labor, dated 07-01-12, establish requirements for Federal Occupational Safety and Health (FEOSH) programs.

DOE O 322.1C, Pay and Leave Administration and Hours of Duty, dated 01-19-11, establishes requirements and responsibilities for the management of apy, including overtime pay and compensatory time, leave administration, time and attendance reporting, and hours of duty.

WAPA O 340.1D Attachment 1 XX-XX-XX Page 2 of 2

DOE O 341.1A, Federal Employee Health Services and DOE G 341.1-2A, Guide on Federal Employee Occupational Medical Programs, dated 10-18-07, establish requirements and responsibilities for occupational medical, employee assistance, and workers' compensation programs for Federal employees.

DOE O 440.1B, Worker Safety and Health Program for DOE (Including the National Nuclear Security Administration) Federal Employees, dated 05-17-07, establishes the framework for an effective worker protection program that will reduce or prevent injuries, illness, and loses by providing a safe and healthful workplace.

DOE G 440.1-1B, Worker Safety and Health Program for DOE (Including the National Nuclear Security Administration) Federal and Contractor Employees, dated 10-20-11, provides information in developing, managing, and implementing a worker safety and health program.

Office of Personnel Management, Qualifications Standards for General Schedule Positions (Operating Manual), www.opm.gov 2013, establishes standard medical qualification and physical requirements for Federal positions.

http://www.opm.gov/

WAPA O 340.1D Attachment 2 XX-XX-XX Page 1 of 37

POSITIONS WITH PHYSICAL REQUIREMENTS

AND ENVIRONMENTAL FACTORS

The positions below have hazardous/arduous duties and/or physical requirements that require a medical examination per section 7d. Attachment 2 provides a listing of these positions and their associated functional and environmental factors:

1. GS-0018 - Safety and Occupational Health Series*.

2. GS-0028 - Environmental Protection Series*.

3. GS-0080 - Security Administration Series*.

4. GS-0301 - Operations and Maintenance Specialist*.

5. GS-0800 - Engineering Series*.

6. GS-0809 - Construction Control Representative.

7. GS-0401 - Vegetation Management Specialist.

8. WB-2610 - Protection and Communication Craftsman.

9. WB-2610 - Electronic Equipment Craftsman.

10. WB-2610 - Meter and Relay Craftsman.

11. WB-2801 - Lineman.

12. WB-2801 - Lineman – Aerial Observer.

13. WB-2810 - Electrician.

14. WB-2854 - Converter Technician.

15. WB-3502 - Laborer.

16. WB-5716 - Heavy Equipment Operator.

17. WB-5803 - Heavy Duty Equipment Mechanic.

18. AD-0303 - Power System Dispatcher.

*Employees occupying these positions that are exposed to hazards, environmental factors, or are first responders for chemical/hazmat situations are subject to periodic medical examinations, subject to supervisory discretion.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved OMB No. 3206 - 0250

To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useablePage 3 of 8

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

1. Purpose of examination 2. Position Title, Series, and Grade

Pre-placement Other (Specify)_____________________________

3. Brief description of what the position requires the employee to do.

GS-0018, Safety and Occupational Health Series

SAFETY AND OCCUPATIONAL HEALTH SERIES (GS-0018)

1. The major duties of a Safety and Occupational Health professional include conducting inspections of facilities; auditing safety systems; providing technical supervision and serve as technical advisor to field personnel for both construction and maintenance activities.

2. Ancillary duties include providing safety training for employees, monitoring field activities with various test equipment, and on-site hazard assessments.

3. Environmental factors which may be important in this job include:

a. Chemical Exposures. Likely to be exposed to chemicals for controlling vegetation and insects. During occasional or incidental duties, may be exposed to concrete work, painting (possibly lead based), welding fumes, or equipment cleaning and repair. In some Regions, transformers, capacitors, or other such equipment may contain polychlorinated biphenyl (PCB) in the dielectric fluid.

b. Dust. Exposure during construction work, and possibly wind borne dust at other times, and dust from sandblasting, carpentry, and shop work (asbestos).

c. Elevation. Any work above 10,000 feet elevation involves the stresses of high elevation. Work between about 6,000 feet and 10,000 feet elevation may involve high altitude stress if the worker is not acclimated to the altitude.

d. Noise. High levels related to operation of heavy equipment, jack hammers, air tools, carpentry equipment, and repair shop.

e. Temperature. Hot in summer, particularly in the sun, with little chance for shade (all Regions). Cold in winter in areas of higher elevation and in Western’s more northern Regions.

f. Vegetation and Insects. Consistent with a variety of ecosystems. Of most concern would be stinging and biting insects and contact with allergenic plants such as poison ivy, oak, or sumac.

XX-XX-XX

Attachment 2

KJensen Typewritten Text

KJensen envelope marked “Confidential - Medical”.

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useablePage 4 of 8

Part B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

4. Check the box for each functional requirement in section 4a and each environmental factor in section 4b essential to the duties of this position. List any additional essential factors in the blank spaces. Also, if the position involves law enforcement, air traffic control, or fire fighting, attach the specific medical standards for the information of the examining physician.

4a. Functional Requirements

Heavy lifting, 45 pounds and over

Moderate lifting, 15-44 pounds

Light lifting, under 15 pounds

Heavy carrying, 45 pounds and over

Moderate carrying, 15-44 pounds

Light carrying, under 15 pounds

Straight pulling (_____ hours)

Pulling hand over hand (_____ hours)

Pushing (_____ hours)

Reaching above shoulder

Use of fingers

Both hands required

Walking (______ hours)

Standing (______ hours)

Crawling (______ hours)

Kneeling (______ hours)

Repeated bending (______ hours)

Climbing, legs only (______ hours)

Climbing, use of legs and arms

Both legs required

Operation of crane, truck, tractor, or motor vehicle

Ability for rapid mental and muscular coordination simultaneously

Ability to use and desirability of using firearms

Near vision correctable at 13” to 16” to Jaeger 1 to 4

Far vision correctable in one eye to 20/20 and to 20/40 in the other

Specific visual requirement (specify)

Both eyes required

Depth perception

Ability to distinguish basic colors

Ability to distinguish shades of colors

Hearing (aid permitted)

Hearing without aid

Specific hearing requirements (specify)

Other (specify)

4b. Environmental Factors

Outside

Outside and inside

Excessive heat

Excessive cold

Excessive humidity

Excessive dampness or chilling

Dry atmospheric conditions

Excessive noise, intermittent

Constant noise

Dust

Silica, asbestos, etc.

Fumes, smoke, or gases

Solvents (degreasing agents)

Grease and oils

Radiant energy

Electrical energy

Slippery or uneven walking surfaces

Working around machinery with moving parts

Working around moving objects or vehicles

Working on ladders or scaffolding

Working below ground

Unusual fatigue factors (specify)

Working with hands in water

Explosives

Vibration

Working closely with others

Working alone

Protracted or irregular hours of work

Other (specify)

KJensen Typewritten Text

KJensen Typewritten Text

SAFETY AND OCCUPATIONAL HEALTH SERIES (GS-0018)

KJensen Typewritten Text

KJensen Typewritten Text

KJensen Typewritten Text envelope marked “Confidential - Medical”.

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useablePage 3 of 8

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

1. Purpose of examination 2. Position Title, Series, and Grade

Pre-placement Other (Specify)_____________________________

3. Brief description of what the position requires the employee to do.

GS-0028, Environmental Protection Series

ENVIRONMENTAL PROTECTION SERIES (GS-0028)

1. An Environmental Protection Specialist inspects high voltage transmission equipment, equipment storage and maintenance areas, and other Western facilities to ensure that hazardous wastes and regulated materials are properly stored, and regulated equipment is properly labeled. Other responsibilities include: training, maintenance, construction, and dispatch personnel; ensuring required responses to spills or regulated materials;

sampling soils, equipment, and unknown wastes to determine their characteristics; and surveying environmental conditions at Western facilities, including transmission lines.

2. Environmental factors which may be important in this job include:

a. Chemical Exposures. Likely to be exposed to chemicals for controlling vegetation and insects. During occasional or incidental duties may be exposed to concrete work, painting (possibly lead based), welding fumes, or equipment cleaning and repair. In some Regions, transformers, capacitors, or other such equipment may contain polychlorinated biphenyl (PCB) in the dielectric fluid.

b. Dust. Exposure during construction work, and possibly wind borne dust at other times.

c. Elevation. Any work above 10,000 feet elevation involves the stresses of high elevation. Work between about 6,000 feet and 10,000 feet elevation may involve high altitude stress if the worker is not acclimated to the altitude.

d. Noise. High levels related to operation of heavy equipment and tools.

e. Temperature. Hot in summer, particularly in the sun, with little chance for shade (all Regions). Cold in winter in the more northern Regions, or ones with higher elevations.

f. Vegetation and Insects. Consistent with a variety of ecosystems. Of most concern would be stinging and biting insects and contact with allergenic

KJensen Typewritten Text

KJensen Typewritten Text envelope marked “Confidential - Medical”.

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useablePage 4 of 8

Part B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

4. Check the box for each functional requirement in section 4a and each environmental factor in section 4b essential to the duties of this position. List any additional essential factors in the blank spaces. Also, if the position involves law enforcement, air traffic control, or fire fighting, attach the specific medical standards for the information of the examining physician.

4a. Functional Requirements

Heavy lifting, 45 pounds and over

Moderate lifting, 15-44 pounds

Light lifting, under 15 pounds

Heavy carrying, 45 pounds and over

Moderate carrying, 15-44 pounds

Light carrying, under 15 pounds

Straight pulling (_____ hours)

Pulling hand over hand (_____ hours)

Pushing (_____ hours)

Reaching above shoulder

Use of fingers

Both hands required

Walking (______ hours)

Standing (______ hours)

Crawling (______ hours)

Kneeling (______ hours)

Repeated bending (______ hours)

Climbing, legs only (______ hours)

Climbing, use of legs and arms

Both legs required

Operation of crane, truck, tractor, or motor vehicle

Ability for rapid mental and muscular coordination simultaneously

Ability to use and desirability of using firearms

Near vision correctable at 13” to 16” to Jaeger 1 to 4

Far vision correctable in one eye to 20/20 and to 20/40 in the other

Specific visual requirement (specify)

Both eyes required

Depth perception

Ability to distinguish basic colors

Ability to distinguish shades of colors

Hearing (aid permitted)

Hearing without aid

Specific hearing requirements (specify)

Other (specify)

Excessive heat

Excessive cold

Excessive humidity

Excessive dampness or chilling

Dry atmospheric conditions

Excessive noise, intermittent

Constant noise

Dust

Silica, asbestos, etc.

Fumes, smoke, or gases

Solvents (degreasing agents)

Grease and oils

Radiant energy

Electrical energy

Slippery or uneven walking surfaces

Working around machinery with moving parts

Working around moving objects or vehicles

Working on ladders or scaffolding

Working below ground

Unusual fatigue factors (specify)

Working with hands in water

Explosives

Other (specify)

KJensen

ENVIRONMENTAL PROTECTION SERIES (GS-0028)

envelope marked “Confidential - Medical”.

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useablePage 3 of 8

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

1. Purpose of examination 2. Position Title, Series, and Grade

Pre-placement Other (Specify)_____________________________

3. Brief description of what the position requires the employee to do.

GS-0080, Security Administration Series

SECURITY ADMINISTRATION SERIES (GS-0080)

1. The major duties of a Security professional include conducting security inspections of facilities, audit and risk assessments of security systems, security studies, and providing technical advice and supervision and serves as a technical advisor.

2. Ancillary duties include providing security awareness training for employees, investigation of security incidents, and performing general technical tasks of a physical security program.

3. Physical factors of this job may include:

a. Elevation. Any work above 10,000 feet elevation involves the stresses of high elevation. Work between about 6,000 feet and 10,000 feet elevation may involve high altitude stress if the worker is not acclimated to the altitude.

b. Noise. High levels related to operation of heavy equipment, jack hammers, air tools, and carpentry equipment.

c. Temperature. Hot in summer, particularly in the sun, with little chance for shade (all Regions). Cold in winter in the more northern Regions, or ones with higher elevations.

d. Vegetation and Insects. Consistent with a variety of ecosystems. Of most concern would be stinging and biting insects and contact with allergenic envelope marked “Confidential - Medical”.

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useablePage 4 of 8

Part B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

4. Check the box for each functional requirement in section 4a and each environmental factor in section 4b essential to the duties of this position. List any additional essential factors in the blank spaces. Also, if the position involves law enforcement, air traffic control, or fire fighting, attach the specific medical standards for the information of the examining physician.

4a. Functional Requirements

Heavy lifting, 45 pounds and over

Moderate lifting, 15-44 pounds

Light lifting, under 15 pounds

Heavy carrying, 45 pounds and over

Moderate carrying, 15-44 pounds

Light carrying, under 15 pounds

Straight pulling (_____ hours)

Pulling hand over hand (_____ hours)

Pushing (_____ hours)

Reaching above shoulder

Use of fingers

Both hands required

Walking (______ hours)

Standing (______ hours)

Crawling (______ hours)

Kneeling (______ hours)

Repeated bending (______ hours)

Climbing, legs only (______ hours)

Climbing, use of legs and arms

Both legs required

Operation of crane, truck, tractor, or motor vehicle

Ability for rapid mental and muscular coordination simultaneously

Ability to use and desirability of using firearms

Near vision correctable at 13” to 16” to Jaeger 1 to 4

Far vision correctable in one eye to 20/20 and to 20/40 in the other

Specific visual requirement (specify)

Both eyes required

Depth perception

Ability to distinguish basic colors

Ability to distinguish shades of colors

Hearing (aid permitted)

Hearing without aid

Specific hearing requirements (specify)

Other (specify)

Excessive heat

Excessive cold

Excessive humidity

Excessive dampness or chilling

Dry atmospheric conditions

Excessive noise, intermittent

Constant noise

Dust

Silica, asbestos, etc.

Fumes, smoke, or gases

Solvents (degreasing agents)

Grease and oils

Radiant energy

Electrical energy

Slippery or uneven walking surfaces

Working around machinery with moving parts

Working around moving objects or vehicles

Working on ladders or scaffolding

Working below ground

Unusual fatigue factors (specify)

Working with hands in water

Explosives

Other (specify)

KJensen

SECURITY ADMINISTRATION SERIES (GS-0080)

envelope marked “Confidential - Medical”.

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useablePage 3 of 8

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

1. Purpose of examination 2. Position Title, Series, and Grade

Pre-placement Other (Specify)_____________________________

3. Brief description of what the position requires the employee to do.

GS-0301, Operations and Maintenance Specialist

OPERATIONS AND MAINTENANCE SPECIALIST (GS-0301)

1. Major duties of an Operations and Maintenance Specialist are planning, organization, scheduling and coordination of work. This work includes regular preventive maintenance, periodic testing, emergency repair, system replacements and new construction. Reviews construction specifications, new Emergency Orders, Standard Operating Procedures, safety and environmental orders, and other operating instructions to assure efficiency and proper utilization of manpower. Develops statement of work and is the Contracting Officer Representative for service contracts which may include facility janitorial, security gates, weed spraying, etc. Coordinates Doble testing. Works with the environmental office to ensure maintenance personnel are up to date on regulations that may affect the power system. Assists personnel with the training and instruction programs in the area of live-line transmission system maintenance, substation, metering, and communication equipment and test equipment. Assists with the scheduling of the Division’s heavy equipment and coordinates heavy equipment work with other Divisions. Coordinates the maintenance of heavy equipment. The work requires frequent and recurring inspection of and maintenance on electrical circuits or equipment located in the field at power plants, substations, metering station, microwave sites or portion of the transmission system. This requires frequent walking, climbing, stooping and bending.

2. Environmental factors which may be important in this job include:

a. Chemical Exposures. Likely to be exposed to chemicals for controlling vegetation and insects. May be exposed to wood preservatives during climbing and handling wood poles. During occasional or incidental duties may be exposed to concrete work, painting (possibly lead-based), or equipment cleaning and repair. In some Regions transformers, capacitors, or other such equipment may contain polychlorinated biphenyl (PCB) in the dielectric fluid. May be exposed to welding fumes.

b. Dust. Exposure during construction work, and possibly wind borne dust at other times.

c. Elevation. Any work above 10,000 feet elevation involves the stresses of high elevation. Work between about 6,000 feet and 10,000 feet elevation may involve high altitude stress if the worker is not acclimated to the altitude.

d. Noise. High levels related to the operation of heavy equipment and tools.

e. Temperature. Hot in summer, particularly in the sun with little chance for shade (all Regions). Cold in winter in the more northern Regions, or ones with higher elevations.

f. Vegetation and Insects. Consistent with a variety of ecosystems. Of most concern would be stinging and biting insects and contact with allergenic plants such as poison ivy, oak or sumac.

3. Applicable Standards:

a. The Federal Motor Carrier Safety Regulations (49 C.F.R. § 391.41 to 391.49), dated 10-01-11, cover many aspects of physical and mental requirements for driving heavy duty trucks.

b. OSHA has standards for hearing conservation programs for when an employee’s noise exposure equals or exceeds an 8-hour time-weighted average sound level of 85 decibels measured on the A scale or, equivalently, a dose of 50 percent of permissible exposure. This standard includes standards for the audiometric testing equipment, the frequency and conduct of the tests, and the interpretation of the results. These standards are found in 29 C.F.R.

WAPA 340.1D

envelope marked “Confidential - Medical”.

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useablePage 4 of 8

Part B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

4. Check the box for each functional requirement in section 4a and each environmental factor in section 4b essential to the duties of this position. List any additional essential factors in the blank spaces. Also, if the position involves law enforcement, air traffic control, or fire fighting, attach the specific medical standards for the information of the examining physician.

4a. Functional Requirements

Heavy lifting, 45 pounds and over

Moderate lifting, 15-44 pounds

Light lifting, under 15 pounds

Heavy carrying, 45 pounds and over

Moderate carrying, 15-44 pounds

Light carrying, under 15 pounds

Straight pulling (_____ hours)

Pulling hand over hand (_____ hours)

Pushing (_____ hours)

Reaching above shoulder

Use of fingers

Both hands required

Walking (______ hours)

Standing (______ hours)

Crawling (______ hours)

Kneeling (______ hours)

Repeated bending (______ hours)

Climbing, legs only (______ hours)

Climbing, use of legs and arms

Both legs required

Operation of crane, truck, tractor, or motor vehicle

Ability for rapid mental and muscular coordination simultaneously

Ability to use and desirability of using firearms

Near vision correctable at 13” to 16” to Jaeger 1 to 4

Far vision correctable in one eye to 20/20 and to 20/40 in the other

Specific visual requirement (specify)

Both eyes required

Depth perception

Ability to distinguish basic colors

Ability to distinguish shades of colors

Hearing (aid permitted)

Hearing without aid

Specific hearing requirements (specify)

Other (specify)

Excessive heat

Excessive cold

Excessive humidity

Excessive dampness or chilling

Dry atmospheric conditions

Excessive noise, intermittent

Constant noise

Dust

Silica, asbestos, etc.

Fumes, smoke, or gases

Solvents (degreasing agents)

Grease and oils

Radiant energy

Electrical energy

Slippery or uneven walking surfaces

Working around machinery with moving parts

Working around moving objects or vehicles

Working on ladders or scaffolding

Working below ground

Unusual fatigue factors (specify)

Working with hands in water

Explosives

Other (specify)

WAPA 340.1D

KJensen Typewritten Text

KJensen Typewritten Text OPERATIONS AND mAINTENANCE SPECIALIST (GS-0301) envelope marked “Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved OMB No. 3206 - 0250

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useable Page 3 of 8

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

1. Purpose of examination

Pre-placement Other (Specify)

2. Position Title, Series, and Grade

GS-0800, Engineering Series

ENGINEERING SERIES (GS-0800)

1. Employees in the engineering series who work in a substation environment are involved in field, shop, or laboratory activities and may be exposed to environmental hazards. Majority of work is accomplished at field sites and is more strenuous. Work may require considerable walking, bending, or climbing when making visits to construction sites, substations or communication sites. May be subject to inclement weather and hours of work outside a normal tour of duty. Work may be performed around energized, high-voltage electrical equipment. Operates pickup truck or sedan to travel to job sites.

2. Environmental factors which may be important in this job include:

a. Chemical Exposures. Likely to be exposed to chemicals for controlling vegetation and insects. During occasional or incidental duties may be exposed to concrete work, painting (possibly lead based), welding fumes, or equipment cleaning and repair. In some Regions, transformers, capacitors, or other such equipment may contain polychlorinated biphenyl (PCB) in the dielectric fluid.

b. Dust. Exposure during construction work, and possibly wind borne dust at other times.

c. Elevation. Any work above 10,000 feet elevation involves the stresses of high elevation. Work between about 6,000 feet and 10,000 feet elevation may involve high altitude stress if the worker is not acclimated to the altitude.

d. Noise. High levels related to operation of heavy equipment and tools.

e. Temperature. Hot in summer, particularly in the sun, with little chance for shade (all Regions). Cold in winter in the more northern Regions, or ones with higher elevations.

f. Vegetation and Insects. Consistent with a variety of ecosystems. Of most concern would be stinging and biting insects and contact with allergenic

WAPA 0 340.1D

KJensen Typewritten Text

KJensen Typewritten Text

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U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only

Optional Form 178 July 2009

Formerly SF 78 Previous editions not useablePage 4 of 8

Part B. CONTINUED - TO BE COMPLETED…