Attach_36_Occupational_Health_Procedures.pdf

Medical Support Services

Center for Domestic Preparedness (CDP)

Anniston, AL

Attachment 36

Occupational Health Procedures

FOR OFFICIAL USE ONLY

STANDARD OPERATING PROCEDURE

Organization: Center for Domestic Preparedness Date: June 12, 2014

Title: Occupational Health Procedures

CDP-COBRATF-OH SOP 001.0

Purpose I.

To establish guidelines for the following occupational health procedures: medical surveillance of personnel and pregnant female employees, respiratory screening, and occupational eyewear.

Supersession II.

This SOP supersedes:

A. SOP 19.1.1, Medical Surveillance of Pregnant Female Employees, Effective 05/20/2013

B. SOP 19.2.1, Medical Surveillance of Personnel, Effective 05/06/2013

C. SOP 19.3.0, Occupational Health Respiratory Protection, Effective 04/18/2012

D. SOP 19.4.0, Requesting Occupational Eyewear, Effective 04/18/2012

Authority III.

COBRATF Chemical Surety Program Standards Document

References IV.

A. OSHA 29 CFR 1910.133, Personal Protective Equipment

B. OSHA 29 CFR 1910.134, Respiratory Protection

C. OSHA 29 CFR 1910.1200, Hazard Communication

D. Textbook of Occupational Medicine, Carl Zenz

E. Occupational and Environmental Medicine, Robert McCunney

F. University of New South Wales, Embryology, Hill, Mark, “Abnormal Development –

Maternal Hyperthermia,” 2006

G. The Journal of Maternal-Fetal and Neonatal Medicine, Lindquist, PG, March 1, 2003

Acronyms and Definitions V.

A. AD – Assistant Director

B. CBC – Complete Blood Count

C. CERP – Contractor/Employee Reliability Program

D. CFR – Code of Federal Regulations

E. IAW – In Accordance With

CDP-COBRATF-OH SOP 001.0

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F. IH – Industrial Hygiene

G. MA – Medical Authority

H. OB/GYN – Obstetrics/Gynecology

I. OH – Occupational Health

J. OHN – Occupational Health Nurse

K. OSHA – Occupational Safety & Health Administration

L. PC&E – Protective Clothing and Equipment

M. PE – Physical Exam

N. PM – Project Manager

O. PPE – Personal Protective Equipment

P. RBC-ChE – Red Blood Cell Cholinesterase; enzyme in the blood

Q. SF – Standard Form

Responsible Office VI.

OH Section

Standard Operating Procedures VII.

A. Medical Surveillance of Personnel

1. Physical Examinations: Pre-placement, periodic, and termination physical examinations are performed for CERP personnel, as determined by the medical surveillance category to which they are assigned. The AD ensures that CERP personnel whose job requires the use of a respirator receive medical clearance from the MA to use a respirator as part of the respirator protection program. The respirator clearance issued should be specific to: the type and class of respirators to be worn by the employee, frequency and duration of use, level of exertion/workload, and environmental conditions.

2. Medical examinations are performed by or under the direct supervision of a licensed physician and are provided without cost to the employee, without loss of pay and at a reasonable time and place.

3. Pre-Placement

a. Individuals assigned duty at the COBRATF or placed in the CERP in support of the COBRATF are referred to the OHN for initial evaluation and determination of proper medical surveillance category.

(1) Each individual is required to process through the OHN prior to the pre-placement, periodic, or termination examinations to ensure they have the approved medical screening forms; PMs or federal supervisors are responsible for ensuring individuals process through the OHN prior to examinations.

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(2) Pre-placement examinations are conducted within 90 days prior to work assignments to an area involving potential exposure to nerve agents. If exam exceeds 90 days, the MA meets with the employee to repeat an interim occupational exposure and history questionnaire to determine if changes have occurred. A limit of 180 days should accomplish this practice. Any employee not read into the CERP after 180 days should have the entire medical process repeated.

(3) The AD is notified in writing of any individual that does not process through the OHN prior to the examination or that does not keep their appointment with the MA.

(4) The OHN works with the AD and CHO to determine the individual’s proper medical surveillance category.

(5) The OHN verifies that the individual completed the appropriate medical forms prior to the examination.

b. Employees receive required examinations at the MA’s office scheduled by the

OHN. The OHN notifies each PM or federal supervisor when the exams are due.

4. Upon completion of all examinations, a written opinion from the MA (OHF 001) is provided to the AD. The opinion includes:

a. Any recommendations for further medical follow-ups

b. General results of the medical surveillance examination and associated tests

c. Any medical condition revealed in the course of the examination that may place the individual at increased risk as a result of exposure to a hazardous chemical found in the workplace

d. A statement that the individual has been informed by the MA of the results of the consultation or medical examination and any medical condition that may require further examination or treatment

e. Medical conditions occurring between examinations are reported to the Nurse

Practitioner or the OHN, documented on OHF 010, and provided to the AD with recommendations for limitations or restrictions

5. Medical Surveillance Categories

a. The AD, in conjunction with the CHO and OHN, ensures COBRATF personnel are considered for Category I or Category II.

b. Category I are workers with a high potential for exposure to chemical agents or those who work with neat agent routinely.

c. Category II are workers assigned to the COBRATF with a low potential for exposure to chemical agents but whose job requirements potentially involve the wearing of protective ensembles during training and emergency response.

d. Medical examinations are performed based on the medical surveillance category to which the individual has been assigned, as depicted below.

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Category Post-Offer, Pre-Placement Periodic Termination

I Occupational History (OH) Interval OH Interval OH

Medical History (MH) Interval MH Interval MH

Physical Exam Phys. Exam Phys. Exam

Electrocardiogram (EKG) EKG RBC-ChE

Spirometry baseline Spirometry

Respirator clearance Respirator clearance

Audiometric exam Audiometric exam

Visual Acuity Visual Acuity

Pupil size & reactivity Pupil size & reactivity

Baseline RBC-ChE RBC-ChE2

CBC with diff

II OH Interval OH Interval OH

MH Interval MH Interval MH

Spirometry baseline Spirometry RBC-ChE

Respirator clearance Respirator clearance

Visual Acuity Visual Acuity

Baseline RBC-ChE RBC-ChE

Denotes annual requirement unless otherwise specified.

Re-establish baseline by a two-sample blood draw at least every three (3) years.

e. Category I personnel receive:

(1) Comprehensive occupational history (OHF 002) with specific emphasis on prior potential exposure to cholinesterase-inhibiting substances

(2) Medical history (OHF 003) and review of systems, focusing on potentially disqualifying factors

(3) General physical examination with emphasis on cardiovascular, pulmonary disease, neurological disease, visual acuity, hearing deficits, and skin diseases

(4) EKG

(5) Spirometry baseline

(6) Audiogram

(7) CBC with differential

(8) Near and distant visual acuity (OHF 004) with pupil size and reactivity assessed in a darkened room.

(9) PPE evaluation, to include respiratory screening (OHF 005) and clearance

(10) RBC-ChE baseline determination (OHF 006)

f. Category II personnel receive:

(1) Comprehensive occupational history with specific emphasis on prior potential exposures to cholinesterase-inhibiting substances

(2) Medical history

(3) Spirometry baseline

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(4) Respiratory screening and clearance

(5) Near and distant visual acuity

(6) RBC-ChE baseline determination

6. Periodic Medical Surveillance

a. Category I personnel receive annual examination, conducted during the same month as the previous exam or earlier, to determine continued fitness to include requirements in Section VII.B.5.a, except there is no CBC with differential or

RBC-ChE baseline required.

b. Category II personnel receive annual examination, conducted during the same month as the previous exam or earlier, to determine continued fitness to include requirements in Section VII.B.5.b, except there in no RBC-ChE baseline required.

7. Termination Examinations

a. Termination examinations are performed within 30 days before or after removal from the medical surveillance program and documented on OHF 009.

b. Category I personnel receive:

(1) Occupational history

(2) Medical history

(3) Physical exam

(4) Termination RBC-ChE

c. Category II personnel receive:

(1) Occupational history

(2) Medical history

(3) Termination RBC-ChE

8. Potential Exposures:

a. Employees who sustain a potential exposure to nerve agent have the opportunity to receive medical attention and a potential exposure evaluation (OHF 007) whenever any of the following occurs:

(1) When a person develops signs or symptoms consistent with an exposure to nerve agent.

(2) When exposure monitoring for unprotected personnel reveals an exposure dose (concentration x time) above the applicable Center for Disease Control

Airborne Exposure Limit based dose.

(3) When an exposure control element (engineering, administrative, PPE) fails resulting in the likelihood of overexposure (glove tear, breach of protective mask seal, etc.).

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(4) When exposure monitoring for a respiratory protected person reveals an exposure dose (concentration x time) above the applicable COBRATF

Maximum Use Concentration.

b. The AD provides the following information to the MA:

(1) Identity of the nerve agent to which the individual may have been exposed.

(2) A description of conditions under which the exposure occurred, including quantitative exposure data, if available.

(3) The duration of exposure, route of exposure, and level of PPE worn, if known.

(4) A description of the signs and symptoms of exposure the individual is experiencing, (if any), and any first aid or treatment given.

9. RBC-ChE Determinations

a. Blood samples for RBC ChE determinations are analyzed by the CDP lab. The

CDP ensures that quality assurance oversight of the RBC-ChE analysis laboratory is provided by the U.S. Army Public Health Command. Costs of RBC-ChE sample analysis are paid by the CDP. Additional RBC-ChE determinations required at the contractors' discretion shall be paid for by the contractor.

b. A RBC-ChE baseline is established before an individual is permitted to work with toxic agents and is re-established at least every three (3) years. The baseline is determined by taking two blood samples at least twenty-four (24) hours but no more than fourteen (14) days apart. During the time between the two RBC-ChE measurements, the individual is not allowed to enter chemical agent areas. If the two samples differ by more than 0.05 delta pH units, a third sample will be taken within fourteen (14) days of the last specimen drawn, and the baseline will be an average of the three. The MA must approve any adjustment of the baseline value.

The approved reestablished baseline is annotated on SF 512 or local equivalent

“Reestablished Baseline” with the date of the approval and initials of the MA.

c. Results of all RBC-ChE analyses are recorded on a SF 512, or local equivalent.

Results of each sample submitted for the baseline establishment (two or three depending on the results) and the date of those samples are entered on the chart. A line (the average of the samples) is drawn across the chart and annotated as

"baseline”. Lines representing action levels [ten (10) and twenty-five (25) percent depression and ten (10) percent elevation changes from the baseline] are also drawn across the chart. Additional RBC-ChE determinations may be necessary if the individual is potentially exposed to chemical agent or at the physician’s discretion. The SF 512 or local equivalent shall also be annotated to denote termination RBC-ChE and any length of time when an individual was removed from the medical surveillance program.

d. Over a period of time, it is normal for the RBC-ChE baseline to change in some workers. This variation reflects the natural physiological enzyme variance in humans. The MA reviews variations greater than +/- ten (10) percent. Resolution of the variation is documented in the medical record.

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e. An individual's RBC ChE level is determined when signs and symptoms of systemic chemical agent exposure are apparent. In addition, local signs such as miosis or localized sweating necessitate an immediate RBC ChE sample collection and removal of the individual from further potential exposure until results of the analysis are known. In any instance where it is suspected or known that an individual has experienced a compromise in personal protective clothing, equipment or engineering controls, which has potentially resulted in an exposure to chemical agent, an RBC ChE determination is made.

f. The MA examines any individual presenting symptoms for medical attention meeting the criteria of Section VII.A.8.a above. The results of this potential exposure evaluation are recorded on a potential exposure evaluation clinical record form. Appropriate monitoring is conducted in the laboratory or area where the individual was thought to be or was known to have been exposed. The MA provides appropriate medical examinations and emergency treatment and sends a blood sample to the blood lab designated by the CDP for RBC ChE determination.

The MA or OHN also documents the individual's occupational health record with an opinion of the exposure effect and records in the individual's occupational health record any atmospheric monitoring measurements provided by the AD. The

MA will not allow any employee who has undergone a potential exposure evaluation for nerve agents to return to duty in a nerve agent operating area until the absence of an RBC-ChE depression from baseline greater than 10% has been verified.

g. If depression of the RBC-ChE is greater than twenty-five (25) percent from the baseline value, the individual is removed from chemical agent work and referred to the MA. The individual will not resume chemical agent duties until RBC-ChE levels have returned to within ten (10) percent of the baseline and the individual has been asymptomatic for at least one (1) week.

B. Respiratory Protection

1. Prior to issue of respiratory protection equipment, the OHN ensures employees at the

COBRATF have a pre-placement evaluation performed by the MA which, at a minimum, consists of the following:

a. Medical history with special emphasis on visual, dermatologic, or respiratory problems (i.e., asthma, bronchitis, pulmonary surgery). Emotional problems, hysteria, claustrophobia, and smoking history should be recorded.

b. Occupational history to include previous usage of respiratory protection, any problems with mask wearing, and recent and past history of exposure to potential hazards.

c. Physical examination for Category I personnel and upon discretion of the MA for

Category II, focusing on the respiratory system.

d. PPE evaluation to include respiratory screening and spirometry.

e. Mask “use” test under observation, upon discretion of the MA and/or OHN.

f. X-ray or other lab testing, upon the discretion of the MA.

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g. Blood pressure.

2. For continuing use of respiratory protection equipment, the OHN ensures employees at the COBRATF have a periodic evaluation performed by the MA which, at a minimum, consists of the following:

a. Review of interval medical history to include significant health changes since last examination.

b. Review of occupational history, focusing on problems wearing respiratory protection and exposure to potential hazards.

c. Physical exam for Category I personnel and upon discretion of the physician for

Category II personnel.

d. PPE evaluation to include respiratory screening and spirometry.

e. Mask “use” test upon discretion of MA and/or OHN.

f. Blood pressure.

3. A special evaluation should be performed after prolonged absence from work, for medical reasons, or whatever a functional disability has been identified, or at the discretion of the MA.

4. Spirometry testing is performed by a trained technician at the MA’s office. The frequency of spirometry testing is as follows:

a. Baseline upon entry to program for Category I and II.

b. Annually for Category I and II.

c. Whenever specifically requested by MA.

5. Potentially Disqualifying Factors. These factors are not absolute disqualifiers and each case must be considered individually. Final disqualification authority for use of respirator resides with the MA. These conditions, of themselves, may be potentially disqualifying information for purposes of the CERP and need to be provided to the

AD.

a. Facial deformity and/or facial hair. Questionably disqualifying conditions should be evaluated by fit testing.

b. Prescription optical lenses or contact lenses worn when in full face respirator and visual acuity cannot be corrected to regulatory requirement.

c. Hearing requirements based on the nature of work to be performed.

d. Perforated tympanic membranes where inhalation or absorption of toxic materials vapors through the perforation may occur.

e. Respiratory diseases where significant restrictive, obstructive, or perfusion disorders exist.

f. Cardiovascular diseases, (i.e., symptomatic coronary artery disease, significant arrhythmias, or history of recent myocardial infarction).

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g. Endocrine disorders which cause loss of consciousness or loss of response capability.

h. Neurological Disability. Inability to perform coordinated movement and conditions affecting response and consciousness. Epilepsy, controlled on medication, should not be disqualifying if the patient has been seizure-free for 6 months and has no significant side effects from medication.

i. Medications affecting judgment, performance, or reliability.

j. Psychological conditions that affect judgment and reliability. Claustrophobia, if unable to wear equipment after “use” testing. Anxiety, if severe.

6. “Use” Testing (if ordered by the MA or OHN)

a. Testing is conducted in the Occupational Health Section at the COBRATF and is medically supervised by an OHN.

b. Duration of testing and activity during testing is based on an individual’s required usage of respiratory protection and daily job related activity.

7. Notification of Medical Clearance for Respiratory Protective Equipment

a. The AD is notified by the MA of any individual not suitable for utilizing respiratory protective equipment using OHF 001 and OHF 008.

b. The OHN notifies the AD, PMs, PC&E, Safety Officer and Safety Control by memorandum of individuals who are cleared by the MA to wear respiratory protective equipment, and those who require optical inserts or contacts for their respirator. PC&E does not issue a respirator until the OHN has medically cleared the individual by a PE schedule and/or memo and the individual has optical inserts or contact lens, if required.

8. All applicable contract and federal employees receive respiratory screening by the

MA. Each individual is required to process through the OHN prior to their evaluation to ensure they have the approved medical forms. After the exam, a written opinion from the MA (OHN 001) is provided to the AD.

C. Occupational Eyewear

1. Occupational eyewear is an item of both a safety and an operational nature that provides eye protection from dust, flying particles, a vapor or vision correction while wearing protective equipment. This equipment is procured through the contractor or

CDP funds. It does not include normal prescription eyewear or contact lens.

2. All individuals in Category I must have near and distant visual acuity of 20/40 or better in at least one eye (annotated on OHF 004). Individuals not meeting this standard are required to have one pair of optical inserts, or contact lens may be worn.

When a mask is utilized for anything other than escape purposes, Category II individuals not meeting vision standards require one pair of optical inserts, or contact lenses may be worn.

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3. Contract employees order their optical inserts and safety glasses through their companies. Federal employees order through the OHN. Federal and contract employees purchase their own contact lenses.

4. Safety glasses or goggles are used at all times by personnel performing the duties listed as being hazardous enough to warrant purchase of prescription safety glasses or other eye protection.

5. The AD, PMs, PC&E, Safety Officer, and Safety Control are notified in writing of individuals who require optical inserts or contacts for their respirator. The PC&E section will not issue a mask until the OHN medically clears the individual by a PE schedule and/or memo and the individual has optical inserts or contact lenses, if required.

a. Temporary exceptions to this policy may be made on an individual basis at the discretion of the AD for those individuals detailed to jobs not requiring access to chemical agent material, and who will use protective masks only for emergency egress purposes.

b. A memo of any exception is provided to the PC&E section.

c. Safety Control personnel are notified in writing by the OHN of those individuals requiring optical inserts/contact lenses and check to ensure they have the optical inserts in their mask or are wearing contact lenses prior to entry into the chemical agent area.

D. Medical Surveillance of Pregnant Employees

NOTE: Reporting pregnancy is an option for non-CERP employees; however, the OH staff can make appropriate accommodations only if aware of the employee’s specific situation.

1. The MA:

a. Provides medical directives and oversights to ensure proper program management.

He or she is responsible for providing medical expertise concerning the effects of hazards to which a pregnant female may be exposed.

b. Coordinates with Industrial Hygiene to identify reproductive hazards with Safety personnel to determine the most appropriate controls and mitigation strategies.

c. Counsels and advises all pregnant females with respect to workplace hazards and exertion restrictions as indicated (coordinating with the employee’s private physician as appropriate).

d. Advises the affected employee and supervisor regarding need for work accommodations which can be more restrictive than of the employee’s OB/GYN physician but not less restrictive.

2. The Occupational Health Nurse:

a. Plans, coordinates, and implements the program for pregnancy surveillance.

b. Reviews IH data for worksite exposure.

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c. Refers all pregnant females to MA for evaluation and recommendations.

d. Provides follow-up, if ordered by the MA, desired by the individual, or if problems develop.

e. Advises employee to clear through Occupational Health upon return to work from maternity leave.

3. All managers and supervisors advise their employees that a pregnancy surveillance program exists.

4. The CERP Employee:

a. Notifies the OH office of suspected or confirmed pregnancy or any significant change in their health status.

b. Arranges an appointment with the MA for occupational exposure risk assessment and work-related recommendations.

c. Provides the MA with recommendations from their private physician.

5. General

a. Pregnancy, even at an advanced stage, does not necessarily warrant significant restrictions. Most workers in management or administration positions can safely continue with usual duties even to term. Those with more physically demanding duties may require immediate or early restrictions.

b. Repetitive or heavy lifting restrictions are often appropriate at 24 weeks, and are determined on a case-by-case basis subsequent to clinical evaluation by the MA and recommendations from their private OB/GYN.

c. Likewise, heat stress exposure, including the wearing of PPE that may raise core temperature above 100 degrees Fahrenheit should be avoided during pregnancy due to the risk of miscarriage. Therefore, pregnant employees are advised of the risks of such exposure and are encouraged to avoid such situations. The CDP closely works with such individuals on appropriate accommodations in the workplace in such situations, if desired by the employee.

Forms Prescribed VIII.

A. CDP COBRATF OHF 001, CERP Medical Certification Form

B. CDP COBRATF OHF 002, Occupational History

C. CDP COBRATF OHF 003, Medical History

D. CDP COBRATF OHF 004, Vision Screening

E. CDP COBRATF OHF 005, Respiratory Medical Evaluation Questionnaire

F. CDP COBRATF OHF 006, Blood Draw Request

G. CDP COBRATF OHF 007, Potential Exposure Evaluation Clinical Record Form

H. CDP COBRATF OHF 008, Non-CERP Employee Medical Certification Form

(Respirator)

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I. CDP COBRATF OHF 009, CERP and Non-CERP Medical Termination Form

J. CDP COBRATF OHF 010, CERP Medical Notification

K. SF 512, Plotting Chart

APPROVED BY:

Gary L. Milner Date

Assistant Director, COBRATF

Center for Domestic Preparedness

Dr. William Bohannon Date

Medical Authority

Quality Review Date Chemical Hygiene Review Date

(John Blandamer)

Organization: Center for Domestic Preparedness Date: June 12, 2014

Title: Medical Screening of Students Participating in Training

CDP-COBRATF-OH SOP 002.0

I. Purpose

To establish the screening process and medical directives for students participating in chemical agent training.

II. Supersession

This SOP supersedes:

SOP 19.5.0, Medical Screening of Students Participating in Training, Effective 05/22/12

III. Authority

COBRATF Chemical Surety Program Standards Document

IV. References

A. Textbook of Occupational Medicine, Carl Zenz

B. Occupational and Environmental Medicine, Robert McCunney

C. OSHA 29 CFR 1910.134, Respiratory Protection

V. Acronymns and Definitions

A. CAM – Chemical Agent Manager

B. CERP – Contractor/Employee Reliability Program

C. MA – Medical Authority

D. OH – Occupational Health

E. OSHA – Occupational Safety & Health Administration

F. PPE – Personal Protective Equipment

G. RBC-ChE – Red Blood Cell Cholinesterase (enzyme in the blood)

VI. Responsible Office

OH Section

VII. Standard Operating Procedures

A. The OHN:

1. Ensures students complete the Respiratory Medical Evaluation Questionnaire (OHF

013).

2. Serves as secondary screener of the Respiratory Medical Evaluation Questionnaire in accordance with medical directives for the medical questionnaire (Appendix A).

CDP-COBRATF-OH SOP 002.0

3. Ensures blood is drawn for the RBC-ChE testing. One specimen is collected no more than 14 days prior to chemical agent training. Blood is analyzed by the RBC-ChE

Lab.

4. Ensures students have their vital signs taken by the medics before training.

5. Provides immediate verbal or telephonic notification to the Assistant Director and/or

Operations of those students not cleared for training and those that have limitations for training.

6. Ensures students are monitored for at least 30 minutes after each training exercise for signs/symptoms of overexposure to agent GB/VX. Students shall undergo a pupil check for miosis which is conducted by the paramedics.

7. For post-exercise screening, ensures students provide a post training blood sample for

RBC-ChE analysis not earlier than 12 hours after completion of chemical agent training. When an RBC-ChE depression of greater than 20 percent from the pre-blood draw is detected, the RBC-ChE Lab Supervisor or technician notifies the Assistant

Director, the physician and the OHN. The OHN, physician, or other medical representative contacts the individual to notify him or her of the situation and then provides the individual’s personal physician the signs and symptoms of nerve agent exposure (Appendix B). Arrangements are made with the patient’s private physician to collect, prepare and ship RBC-ChE blood samples to the Center for Domestic

Preparedness ChE Lab. The student should be monitored by his or her private physician until the RBC-ChE has reached a value of at least 80 percent of the individual’s RBC-ChE value prior to training, and the individual has been asymptomatic for at least 1 week.

8. Ensures COBRATF medical questionnaires, RBC- ChE results, and patient care reports are forwarded to the CDP archives.

B. Two paramedics (currently licensed by the State of Alabama) are onsite when chemical agent training is in progress. These paramedics respond and render emergency medical treatment to any and all sick, injured, or contaminated personnel. The MA ensures they are trained to render aid to nerve agent victims and trained in proper decontamination procedures in the event of the need for emergency decontamination. No potential nerve agent exposed patient is evacuated from the COBRATF to off post definitive care facilities without verifying the absence of residual nerve agent contamination.

VIII. Forms Prescribed

CDP COBRATF OHF 013, Respiratory Medical Evaluation Questionnaire For Students

William Bohannon Date

Contract Physician

Quality Review Date Chemical Hygiene Officer Date

Appendix A

MEDICAL DIRECTIVES

MODULE 1

EYE AND VISION

STEP QUESTION IF THE ANSWER IS YES

1 EYE AND VISION

1.1 History of

a. Eye disease? Record circumstances and current status.

b. Eye injury? Record circumstances and current status.

c. Eye surgery? Record circumstances and current status.

1.2 Wears corrective lenses? May use optical inserts with respirator.

1.3 Wears contact lenses? May train with contacts at COBRATF.

1.4 Recent changes in vision? Record circumstances and current status.

Near vision? Far vision?

1.5 Current problem with persistent eye strain, Record circumstances and current status.

irritation or pain?

1.6 Test vision if indicated Record. Refer to optometrist as required.

1.7 Inspect external eye if indicated:

a. Yellow sclera? * Record circumstances and current status.

b. Inflamed conjunctiva? * Record circumstances and current status.

c. Inflamed eyelid? * Record circumstances and current status.

1.8 Inspect iris and pupils if indicated:

a. Pinpoint pupils? Record circumstances and current status.

b. Dilated pupils? Record circumstances and current status.

c. Unequal pupils? * Record circumstances and current status.

d. Pupils not reactive to light? * Record circumstances and current status.

1.9 Check cardinal positions of gaze if indicated:

Is paralysis suspected? Record current status. Refer to physician.

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MEDICAL DIRECTIVES

MODULE 2

EAR, NOSE AND THROAT

STEP QUESTION IF THE ANSWER IS YES

2 EAR, NOSE AND THROAT

2.1 History of:

a. Trauma to the ears, nose, throat or sinuses? Record circumstances and current status.

b. Perforated Tympanic Membrane Allow to train at COBRATF with Triple

Flange ear plug. Record.

c. Chronic ear, nose, throat or sinus problems? Record circumstances and current status.

d. Ear, nose or throat surgery? Record circumstances and current status.

2.2 Wears a hearing aid? Record. Hearing aid will not prohibit training.

2.3 Prior exposure to noise? Record circumstances.

2.4 Examine oral cavity, teeth, throat and nasal Record circumstance and current status.

passages, if indicated.

2.5 Examine ears if indicated:

a. Foreign body, inflammation or impacted cerumen in canal? * Record circumstances and current status.

b. Inflamed, ruptured or bulging eardrums? * Record circumstances and current status.

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MEDICAL DIRECTIVES

MODULE 3

NERVOUS SYSTEM AND MENTAL HEALTH

STEP QUESTION IF THE ANSWER IS YES

3 NERVOUS SYSTEM AND MENTAL HEALTH

3.1 History of:

a. Unconsciousness? Record circumstances, frequency and duration. Refer to physician if occurred in past year.

b. Numbness? * Record circumstances, frequency, duration, and current status.

c. Tingling? * Record circumstances, frequency, duration, and current status.

d. Weakness? Record circumstances, frequency and duration. Refer to physician if occurred in past year.

e. Paralysis? Record circumstances, frequency and duration. Refer to physician if occurred in past year.

f. Recurrent dizziness? Record circumstances, frequency and duration. Refer to physician if occurred in past year.

g. Recurrent lightheadedness? Record circumstances, frequency and duration. Refer to physician if occurred in past year.

h. Speech disorders? Record circumstances, frequency and duration. Refer to physician if occurred in past year.

i. Visual disturbances (e.g. double or blurred Record circumstances, frequency and vision)? duration. Refer to physician if occurred in past year.

j. Ataxia or tremors? Record circumstances, frequency and duration. Refer to physician if occurred in past year.

k. Loss of equilibrium? Record circumstances, frequency and duration. Refer to physician if occurred in past year.

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STEP QUESTION IF THE ANSWER IS YES

l. Frequent or recurrent headaches? Record circumstances, frequency and duration. Refer to physician if occurred in past year.

m. Head injury? Record age at time of injury and any complication.

n. Epilepsy or seizures? Record diagnosis, age at onset and treatment plan. Epilepsy, controlled on medication, should not be disqualifying if patient has been seizure-free for 6 months and has no significant side effects from medication.

3.2 History of:

a. Depression or excessive worry? Record circumstances and current status.

b. Sleep disorder? Record circumstances and current status.

c. Alcohol use? Record amount per week and duration of use.

d. Alcoholism? Record circumstances and current status.

e. Drug addiction? Record circumstances and current status.

Refer to physician.

f. Treatment of psychological disorders? Record circumstances and current status.

3.3 Rejection or discharge from military service for Record circumstances and current status.

a psychiatric illness?

3.4 Applied for or received compensation for Record diagnosis, date and current status.

neurological, mental or psychological problem. Refer to physician.

3.5 Check cranial nerves if indicated. Abnormal? Record status. Refer to physician.

3.6 Check peripheral nervous system if indicated.

a. Motor function? Abnormal? Record status. Refer to physician.

b. Sensory function. Abnormal? Record status. Refer to physician.

c. Reflexes. Abnormal? Record status. Refer to physician.

3.7 Evaluate equilibrium, gait and station if indicated.

Abnormal? Record status. Refer to physician.

3.8 During examination, observe dress, grooming and

personal hygiene, facial expression, manner and mood; manner of speech and state and awareness or consciousness. Abnormal? Record circumstances and status.

FOR OFFICIAL USE ONLY 8

STEP QUESTION IF THE ANSWER IS YES

3.9 Evaluate, if indicated, orientation to time and

place, memory skills, intellectual performance and judgment. Abnormal? Record status. Refer to physician.

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MEDICAL DIRECTIVES

MODULE 4

MUSCULOSKELETAL SYSTEM

STEP QUESTION IF THE ANSWER IS YES

4 MUSCULOSKELETAL SYSTEM

4.1 History of:

a. Swollen or painful joints or limbs? Record circumstances and status.

b. Bone, joint or muscular injury or disease? Record circumstances and status.

c. Severe or recurrent back pain? Record circumstances and current status.

d. Arthritis? Record circumstances and current status.

e. Surgery on bones, joints and/or back? Record circumstances and current status.

4.2 Applied for or received medical or disability Record diagnosis, date, disability payment for musculo-skeletal problems (to awarded and current status.

include back related problems)

4.3 Observe for bone, joint or muscular abnormalities. Record abnormalities to include

Abnormal? limitation of range of motion and pain.

4.4 Check the stance and posture. Abnormal? Record circumstances and status.

4.5 Observe gait. Abnormal? Record circumstances and status.

4.6 Examine back and neck if indicated, for:

a. Abnormal curvatures? Record circumstances and status.

b. Limitations or pain on range of motion? Record circumstances and status.

4.7 Examine upper and lower extremities for bone, joint or muscular abnormalities to include range of motion and pain if indicated. Abnormal? Record circumstances and status.

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MEDICAL DIRECTIVES

MODULE 5

RESPIRATORY SYSTEM

STEP QUESTION IF THE ANSWER IS YES

5 RESPIRATORY SYSTEM

5.1 History of:

a. Chronic cough: Record circumstances and current status.

Refer to physician.

b. Sputum production? * Record circumstances and current status.

c. Dyspnea? Record circumstances and current status.

Refer to physician if current.

d. Hemoptysis? Record circumstances and current status.

Refer to physician.

5.2 History of chronic respiratory disease:

a. Hay fever? Record circumstances and current status.

b. Asthma? Record circumstances and current status.

c. Emphysema? Record circumstances and current status.

d. Bronchitis? Record circumstances and current status.

If without rales and rhonchi, patient can train.

e. Lung cancer? Record circumstances and current status.

Refer to physician.

f. Other? Record circumstances and current status.

5.3 History of other respiratory problems:

a. Pneummothorax? Record circumstances and current status.

Refer to physician.

b. Pneumonia or other pulmonary infections? Record circumstances and current status.

c. Other? Record circumstances and current status.

5.4 History of exposures to dusts, mists, fumes, Record circumstances and current status.

smoke, or fibers?

5.5 History of tobacco use? Record type of tobacco use, years of usage, and current status.

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STEP QUESTION IF THE ANSWER IS YES

5.6 Required to use gas mask or respirator on the job? Record type of respirator or device, past problems with respirator usage, level of comfort required while wearing respirator, the environmental conditions under which it is worn, and any history of claustrophobia. If claustrophobic, allow patient to wear mask during outside training. If he wears mask without apparent problem, allow to enter toxic agent area.

5.7 Observe auscultate and percuss chest if indicated

for:

a. Anatomic abnormalities or scars. Abnormal? Record status.

b. Respiratory rate. Abnormal? Record status. Refer to physician.

c. Breath sounds. Abnormal? * Record status.

FOR OFFICIAL USE ONLY 12

MEDICAL DIRECTIVES

MODULE 6

CARDIOVASCULAR SYSTEM

STEP QUESTION IF THE ANSWER IS YES

6 CARDIOVASCULAR SYSTEM

6.1 History of:

a. Heart disease? Record circumstances and current status.

current status. Refer to physician.

b. Chest pain? Record circumstances and current status.

Refer to physician.

c. Hyperlipidemia? Record circumstances and current status.

d. Arrhythmias? Record circumstances and current status.

Refer to physician.

e. Hypertension? Record circumstances and current status.

Refer to physician if elevated per criteria.

f. Circulation problems? Record circumstances and current status.

Refer to physician.

g. Stroke? Record circumstances and current status.

Refer to physician.

h. Heart Surgery? Record circumstances and current status.

Refer to physician if less than 12 months.

i. Tobacco use? Record years of usage and current status.

j. Alcohol use? Record amount per week and duration of use.

6.2 Ascultate and/or palpatate carotid arteries if

indicated. Abnormal? Record status. Refer to physician.

6.3 Measure blood pressure. Abnormal? Record status. Refer to physician, if elevated per criteria.

6.4 Ascultate heart if indicated for:

a. Heart rate and rhythm. Abnormal? Record status. Refer to physician.

b. Heart sounds (to include murmurs, rubs, clicks, etc). Abnormal? Record status. Refer to physician.

FOR OFFICIAL USE ONLY 13

STEP QUESTION IF THE ANSWER IS YES

6.5 Examine, if indicated, extremities for:

a. Edema (pitting)? Record. Refer to physician.

b. Cyanosis? Record. Refer to physician.

c. Varicose veins? Record status.

d. Ulcers? Record. Refer to physician.

FOR OFFICIAL USE ONLY 14

MEDICAL DIRECTIVES

MODULE 7

LIVER

STEP QUESTION IF THE ANSWER IS YES

7 LIVER

7.1 History of:

a. Liver disease (to include hepatitis)? Record circumstances and current status.

Refer to physician if condition current.

b. Gallbladder disease (to include gallstones)? Record circumstances and current status.

c. Jaundice? Record circumstances and current status.

Refer to physician if condition current.

d. Alcohol use Record amount per week and duration of use.

7.2 Previous exposure to hepatoxins e.g. benzene, tuolene? Record current status.

7.3 Observe sclera and skin for icterus. Abnormal? * Record current status.

7.4 Palpatate and/or percuss liver, if indicated, for:

a. Masses? Record. Refer to physician.

b. Pain? Record. Refer to physician

c. Margin (enlarged, hard, irregular)? Record. Refer to physician.

FOR OFFICIAL USE ONLY 15

MEDICAL DIRECTIVES

MODULE 8

GASTROINTESTINAL SYSTEM

STEP QUESTION IF THE ANSWER IS YES

8 GASTROINTESTINAL SYSTEM

8.1 History of:

a. Difficulty swallowing? Record circumstances and current status.

Refer to physician if condition current.

b. Recurrent nausea? * Record circumstances and current status.

c. Persistent vomiting? Record circumstances and current status.

Refer to physician.

d. Chronic indigestion? * Record circumstances and current status.

e. Recent change in weight? * Record circumstances and current status.

f. Eating disorder? Record circumstances and current status.

Refer to physician.

g. Gastritis? Record circumstances and current status.

Refer to physician if current.

h. Ulcer disease? Record circumstances and current status.

Refer to physician if condition current.

i. Stomach or gastric cancer? Record circumstances and current status.

Refer to physician.

8.2 History of:

a. Colitis? Record circumstances and current status.

Refer to physician if condition current.

b. Recurrent diarrhea? Record circumstances and current status.

Refer to physician if condition current.

c. Chronic constipation? Record circumstances and current status.

d. Blood or mucus in stool? Record circumstances and current status.

Refer to physician.

e. Colon or rectal cancer? Record circumstances and current status.

Refer to physician.

8.3 History of abdominal surgery? Record type, complications and date. If surgery in past 3 months refer to physician.

FOR OFFICIAL USE ONLY 16

STEP QUESTION IF THE ANSWER IS YES

8.4 History of pancreatitis? Record circumstances and current status.

Refer to physician if current.

8.5 History of alcohol use? Record amount per week and duration of use.

8.6 Ascultate bowel if indicated. Bowel sounds, Record. Refer to physician if absent or normal? Symptomatic and bowel sounds absent.

8.7 Palpate and percuss abdomen if indicated.

Masses? Pain? Record. Refer to physician as indicated.

FOR OFFICIAL USE ONLY 17

MEDICAL DIRECTIVES

MODULE 9

ENDOCRINE SYSTEM

STEP QUESTION IF THE ANSWER IS YES

9 ENDOCRINE SYSTEM

9.1 History of disorders of the glands to include:

a. Pituitary? Record circumstances and current status.

b. Thyroid? Record circumstances and current status.

c. Parathyroid? Record circumstances and current status.

d. Adrenals? Record circumstances and current status.

e. Pancreas (especially diabetes)? Record circumstances and current status.

If patient is controlled with diet, exercise or medication, he/she can train.

f. Gonads? Record circumstances and current status.

9.2 History of:

a. Growth abnormalities? Record circumstances and current status.

b. Unexplained weight changes? * Record circumstances and current status.

c. Unexplained fever? Record circumstances and current status.

Refer to physician.

d. Rapid pulse? Record circumstances and current status.

Refer to physician if indicated.

e. Intolerance to heat or cold? Record circumstances and current status.

9.3 History of surgery of the glands such as:

a. Thyroid? Record circumstances and current status.

b. Gonads? Record circumstances and current status.

c. Other? Record circumstances and current status.

9.4 Observe for exophtalmos. Present? * Record current status.

9.5 Palpate thyroid for mass if indicated, such as

indicated, such as goiter. Present? * Record current status.

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MEDICAL DIRECTIVES

MODULE 10

IMMUNE SYSTEM

STEP QUESTION IF THE ANSWER IS YES

10 IMMUNE SYSTEM

10.1 History of use of steroids or other Record circumstances and current status.

immunosuppressants? Evaluate prior to bio training. Refer to physician.

10.2 History of:

a. Recurrent infections? Record circumstances and current status.

Refer to physician if condition current.

b. Malignancy? Record circumstances and current status.

Refer to physician if condition current.

c. Autoimmune disease? Record circumstances and current status.

Refer to physician if condition current.

10.3 History of allergies? Record current status.

10.4 History of exposure to:

a. Ionizing radiation? Record circumstances and current status.

b. Chemotherapeutic agents? Record circumstances and current status.

c. Benzene or other unsaturated aromatics? Record circumstances and current status.

d. AIDS virus? Record circumstances and current status.

Refer to physician. Training not prohibited.

10.5 Palpate liver, spleen and lymph nodes if indicated.

Abnormal? * Record status.

FOR OFFICIAL USE ONLY 19

MEDICAL DIRECTIVES

MODULE 11

HEMATOLOGY

STEP QUESTION IF THE ANSWER IS YES

11 HEMATOLOGY

11.1 History of blood dyscrasias:

a. Leukemia? Record circumstances and current status.

Refer to physician if condition current.

b. Anemia? Record circumstances and current status.

Refer to physician if condition current.

c. Leukopenia? Record circumstances and current status.

Refer to physician if condition current.

d. Thrombocytopenia? Record circumstances and current status.

Refer to physician if condition current.

e. Other disorders of blood and blood forming Record circumstances and current status.

and blood forming organs? Refer to physician if condition current.

11.2 History of excessive bleeding following injury Record circumstances and current status.

or tooth extraction.

11.3 History of transfusion of whole blood, platelets Record circumstances and current status.

of plasma?

11.4 History of exposure to hematologic toxins, Record circumstances and current status.

(e. g., benzene, ionizing radiation)?

11.5 Inspect skin for:

a. Multiple or severe ecchmoses? Record. Refer to physician.

b. Multiple petechiae? Record. Refer to physician.

c. Excessive pallor? Record. Refer to physician.

d. Excessive rubor? Record. Refer to physician.

e. Cyanosis? Record. Refer to physician.

FOR OFFICIAL USE ONLY 20

MEDICAL DIRECTIVES

MODULE 12

DERMATOLOGY

STEP QUESTION IF THE ANSWER IS YES

12 DERMATOLOGY

12.1 History of:

a. Severe acne? Record circumstances and current status.

Refer to physician if open areas

b. Eczema? Record circumstances and current status.

Refer to physician if open areas

c. Recurrent dermatitis? Record circumstances and current status.

Refer to physician if condition current.

d. Skin tumors/cancer? Record circumstances and current status.

Refer to physician if condition current.

e. Slow healing wounds? * Record circumstances and current status.

f. Recurrent hives? Record circumstances and current status.

Refer to physician if condition current.

g. Other skin disorders? Record circumstances and current status.

12.2 History of skin problems associated with Record circumstances and current status.

sunlight or chemicals?

12.3 Inspect skin if indicated for:

a. Skin color (e.g., excessive rubor or pallor)?

Abnormal? Record. Refer to physician.

b. Temperature (e.g., clammy)? Abnormal? Record. Refer to physician.

c. Texture? Abnormal? Record circumstances and status.

d. Hydration? Abnormal? Record. Refer to physician.

FOR OFFICIAL USE ONLY 21

STEP QUESTION IF THE ANSWER IS YES

12.4 Inspect skin if indicated for lesions:

a. Fissuring? Record. Refer to physician.

b. Scaling? Record status.

c. Inflammation? Record status.

d. Growths? Record status.

e. Bruises? Record status.

f. Excoriations? Record status.

g. Other? Record status. Patient can train with a superficial wound if healing well, not infected, and not on face.

FOR OFFICIAL USE ONLY 22

MEDICAL DIRECTIVES

MODULE 13

URINARY TRACT

STEP QUESTION IF THE ANSWER IS YES

13 URINARY TRACT

13.1 History of urinary dysfunction:

a. Frequency? * Record circumstances and current status.

b. Dysuria? * Record circumstances and current status.

c. Polyuria? Record circumstances and current status.

If current problem, refer to physician.

d. Discolored? * Record circumstances and current status.

e. Hematuria? Record circumstances and current status.

If current problem, refer to physician.

f. Hesitancy? Record circumstances and current status.

If current problem, refer to physician.

13.2 History of renal disease:

a. Kidney stones? Record circumstances and current status.

b. Nephritis? Refer to physician if current problem.

Record circumstances and current status.

Refer to physician if current problem.

c. Renal Failure? Record circumstances and current status.

Refer to physician if current problem.

d. Other? Record circumstances and current status.

FOR OFFICIAL USE ONLY 23

MEDICAL DIRECTIVES

MODULE 14

REPRODUCTIVE SYSTEM

STEP QUESTION IF THE ANSWER IS YES

14 REPRODUCTIVE SYSTEM

14.1 Pregnant? Student will not train.

14.2 Spouse pregnant? Record.

14.3 Infertility problem? Record status.

14.4 History of:

a. Stillbirth? Record circumstances.

b. Miscarriage? Record circumstances.

c. Premature or low birth weight children? Record circumstances.

d. Children with congenital abnormalities? Record circumstances.

* Condition or history generally will not prevent training. Student may be advised and referred by screener for evaluation by Private Physician in community or personal Primary Care Physician, as appropriate.

FOR OFFICIAL USE ONLY 24

Appendix B

COBRA TRAINING FACILITY

REPORT TO PHYSICIAN

To Whom It May Concern:

This is to inform you that _____________________ may have been exposed to a cholinesterase-inhibiting compound, which may have been a nerve agent. Information regarding this possible compound is provided below for your information in further monitoring and/or treatment of this individual.

Nerve agents are organophosphorous cholinesterase inhibitors. They inhibit butyrylcholinesterase in the plasma, acetylcholinesterase on the red cell, and the acetylcholinesterase at cholinergic receptor sites in tissue.

The three enzymes are not the same; even the two acetylcholinesterases have slightly different properties, although both have a high affinity for acetylcholine. The blood enzymes provide an estimate of the tissue enzyme activity. After acute exposure to a nerve agent, the erythrocyte enzyme most closely reflects the activity of the tissue enzyme, but during recovery the plasma enzyme activity more closely parallels tissue enzyme activity.

After…