ATT_10_Med_Scrn_form.doc

SAMPLE

Doctor’s Office

MEDICAL SCREENING

FOR

FLIGHT DECK/FLIGHT LINE DUTIES

DATE:

NAME:

LAST FOUR of SSN XXX-XX-

RATE:

COMMAND:

BIRTH DATE:

This member has completed the following medical screening for Flight Deck/Flight Line Duties as noted below:

DATE COMPLETED

1. Completed Annual Audiogram

(Hearing Conservation Program)

2. Completed Annual Eye Screen.

(Sight Conservation)

Member IS/IS NOT Qualified for (CRITICAL/NON-CRITICAL) Flight Deck, Flight Line Duties.

***ONLY WHILE WEARING CORRECTIVE LENSES***

Member IS/IS NOT Qualified for (CRITICAL/NON-CRITICAL) Flight Deck, Flight Line Duties.

REQUAL DUE DATE:

Medical Representative

Original to: Company Copy to: Training/Safety Office

E

E

E

Student Medical Questionnaire

Resp:

if required and based on proven safe performance, should be decided upon by the Commanding Officer of the ship based on recommendations from his Senior Medical Officer or SMDR and Safety Officer.

All:

DVA/NVA: Must corrected to 20/20-0 (However, if AFVT or Goodlite letters are used a score of 7/10 on the 20/20 line constitutes meeting visual acuity requirements). Correction must be worn at all times.

MOTILITY: NOHOSH COLOR VISION: Must pass FALANT, PIP, or ISHIHARA.

DEPTH:

AFVT A-B, Verhoeff 8/8, TITMUS, or RANDOT to 40 arc seconds.

Depth Perception: Test-_______________ Pass/Fail

Color Vision: FALANT: Pass- ____ Fail-____ PIP: Pass-____ Fail-____

ISHIHARA: Pass-____ Fail-____

DVA: Uncorrected Corrected NVA: Uncorrected Corrected

OD 20/ 20/ OD 20/ 20/

OS 20/ 20/ OS 20/ 20/

Refer to Optometry: Yes/No

Corrective Lenses Required in Performance of Duties: Yes/No

Last Physical Exam:______________ Immunizations Current: Yes/No

Annual Audiogram Completed: Yes/No STS: Yes/No

Are there any significant medical issues that preclude Flight Deck Duty? Yes/ No

If Yes, List:_____________________________________________________________________________________

If for any reason you are placed on any medications or begin taking medications or supplements, you are required to inform the ship’s Medical Department Representative.

Signature of Patient:____________________ Date:________________

Signature of MDR:_____________________ Date:________________

PATIENT’S NAME (Last, First, Middle Initial)

SEX

RELATIONSHIP TO SPONSOR

STATUS

RANK/GRADE

SPONSOR’S NAME

ORGANIZATION

DEPART./SERVICE

SSN/IDENTIFICATION NO.

DATE OF BIRTH

CHRONOLOGICAL RECORD OF MEDICAL CARE : STANDARD FORM 600 (REV. 5-84)

Prescribed by GSA and ICMR