Occupational Medical Surveillance and Medical Qualification - DoDM 6055.05.pdf

DOD MANUAL 6055.05

OCCUPATIONAL MEDICAL EXAMINATIONS: MEDICAL

SURVEILLANCE AND MEDICAL QUALIFICATION

Originating Component: Office of the Under Secretary of Defense for Personnel and Readiness

Effective: July 27, 2022

Releasability: Cleared for public release. Available on the Directives Division Website at https://www.esd.whs.mil/DD/.

Reissues and Cancels: DoD 6055.05-M, “Occupational Medical Examinations and Surveillance

Manual,” May 2, 2007, as amended

Approved by: Shawn G. Skelly, Assistant Secretary of Defense for Readiness

Purpose: In accordance with the authority in DoD Directive 5124.11; the April 10, 2019 Deputy Secretary of Defense Memorandum; and DoD Instruction (DoDI) 6055.05, this issuance implements policy, assigns responsibilities, and provides the procedures for developing and conducting occupational medical examinations for:

• Medical surveillance to determine the impact of health risks associated with specific jobs, processes, and exposures.

• Medical qualification determination for employment.

DoDM 6055.05, July 27, 2022

TABLE OF CONTENTS 2

TABLE OF CONTENTS

SECTION 1: GENERAL ISSUANCE INFORMATION

1.1. Applicability

1.2. Policy

SECTION 2: RESPONSIBILITIES

DoD Component Heads

SECTION 3: OVERVIEW OF MEDICAL SURVEILLANCE AND QUALIFICATION EXAMINATIONS

3.1. Purpose

a. Medical Surveillance Examinations

b. Medical Qualification Examinations

3.2. Documentation of the Examination

3.3. Communication

a. Examinee

b. Supervisor or HR Personnel

3.4. Refusal to Participate in Examinations

a. Service Members

b. Civilian Employees (Appropriated Fund (APF) Governed by Title 5, CFR)

c. NAF Employees

3.5. Payment for Medical Examinations

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS

4.1. Overview

4.2. Identify Employees with Potentially Hazardous Workplace Exposures

4.3. Determine Availability of Medical Surveillance Guidance for Workplace Hazards

4.4. Enroll Individual Employees in Medical Surveillance Programs

4.5. Identify Medical Surveillance Examination Procedures

4.6. Perform Medical Surveillance

4.7. Report Medical Surveillance

4.8. Prepare for Future Medical Surveillance Evaluation Cycle

SECTION 5: POSITION- AND TASK-SPECIFIC PROCEDURES FOR MEDICAL SURVEILLANCE

EXAMINATIONS

5.1. Overview

5.2. Medical Surveillance for OSHA- and DoD-Regulated Hazards

5.3. Medical Surveillance Considerations for Reproductive Health

a. General

b. Additional Policies and Technical Guidance

c. Medical Surveillance Considerations for Pregnant Workers

d. Medical Surveillance Considerations for Breastfeeding Workers

5.4. Medical Surveillance Considerations for Nanomaterial Workers

a. Description of Nanomaterials

b. Medical Surveillance

5.5. Medical Surveillance for Laser Workers

5.6. Medical Surveillance for Workers Exposed to Electromagnetic Frequency Radiation. 27

5.7. Medical Surveillance for Pest Management Personnel

TABLE OF CONTENTS 3

a. Medical Surveillance for Personnel Who Work with Cholinesterase-Inhibiting Pesticides

b. Medical Surveillance for Other Pest Management Professionals

5.8. Medical Surveillance for Workers Exposed to Hazardous Noise

a. General Requirements

b. Service-Unique HCP Requirements

5.9. Medical Surveillance for Workers Exposed to Lead

a. General

b. Medical Surveillance Requirements

c. Employee Notification

d. Deviation from Requirements

e. Chelating Therapy Guidelines

5.10. Medical Surveillance for Ionizing Radiation Workers

5.11. Medical Surveillance for Explosive Ordnance Disposal (EOD) Personnel

5.12. Medical Surveillance for Respiratory Hazards

5.13. Exposure Assessment for Per- and Polyfluoroalkyl Substances in DoD Firefighters. . 39

SECTION 6: GENERAL PROCEDURES FOR MEDICAL QUALIFICATION EXAMINATIONS

6.1. Overview

a. General

b. Overview for DoD Civilian Employees

c. Roles and Responsibilities

6.2. Requesting and Scheduling Medical Qualification Examinations

a. Authorization to Request Examinations

b. Timing of Examinations

6.3. Content of Medical Qualification Examinations

a. General

b. History

c. Physical Examination

d. Ancillary and Supporting Tests

6.4. Interpretation, Documentation, and Notification of Medical Qualification Determination

a. Interpretation of Examination Findings

b. Documentation of Examination

c. Notification of Examination Results to the Authorized Requesting Official

d. Examinee Notification of Examination Results

6.5. Medical Qualification Examinations for Specific Groups

6.6. Medical Qualification Examinations for Firefighters

a. General Considerations for the Firefighter Examination

b. Guidelines for Medical Evaluation of Firefighters

6.7. Medical Qualification Examinations for Police Officers and Security Guards

a. Purpose of the Police Officer and Security Guard Examination

b. Guidelines for Medical Evaluation of Police Officers and Security Guards

6.8. Medical Qualification Examinations for CMV Operators

6.9. Medical Qualification Examinations for Workers Enrolled in Chemical, Biological, or

Nuclear PRPS

TABLE OF CONTENTS 4

6.10. Medical Qualification Examinations for Child Care and Youth Services Workers

6.11. Medical Qualification Examinations for EOD Personnel

6.12. Medical Qualification for Respiratory Clearance

APPENDIX 6A: OCCUPATIONAL MEDICAL EXAMINATION REQUIREMENTS FOR SELECT

OCCUPATIONS

SECTION 7: OCCUPATIONAL MEDICAL EXAMINATION CONSIDERATIONS

GLOSSARY

G.1. Acronyms G.2. Definitions

REFERENCES

TABLES

Table 1. Examples of Medical Conditions Associated with Workplace Overexposure Table 2. Blood Lead Results and Health-Based Management Requirements Table 3. Occupational Medical Examination Requirements for Firefighters, Police Officers, Security Guards, and EOD Personnel

FIGURE

Figure 1. Necessary HR or Supervisor Actions Before OM Examination

SECTION 1: GENERAL ISSUANCE INFORMATION 5

SECTION 1: GENERAL ISSUANCE INFORMATION

1.1. APPLICABILITY.

This issuance:

a. Applies to:

(1) OSD, the Military Departments, the Office of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant Commands, the Office of Inspector General of the Department of Defense, the Defense Agencies, the DoD Field Activities, and all other organizational entities within the DoD (referred to collectively in this issuance as the “DoD Components”).

(2) All military personnel.

(3) All DoD civilian employees, including nonappropriated fund (NAF) instrumentality employees, unless otherwise noted.

b. Does not apply to:

(1) Medical examinations specified by labor-management agreements.

(2) Medical examinations supporting the accession or retention of military personnel.

(3) General employee health promotion and disease prevention programs conducted under DoDI 1010.10.

(4) DoD civilian employee workers’ compensation policy, treatment, and recordkeeping, in accordance with Volume 810 of DoDI 1400.25.

(5) Non-work-related exposures.

(6) Contractors, unless the DoD is authorized to provide occupational medicine (OM) services to contract personnel as specified in contract documents.

(7) Volunteers, unless an agreement is in place for the DoD to provide OM services.

(8) Foreign nationals, host-nation personnel, or local national personnel, unless the DoD is authorized to provide OM services to such individuals.

(9) Medical and health care services that lead to the traditional provider-patient relationship where there is an obligation to provide personal health care.

(10) The reasonable accommodation process for DoD civilian employees with disabilities conducted pursuant to Part 1630 of Title 29, Code of Federal Regulations (CFR).

SECTION 1: GENERAL ISSUANCE INFORMATION 6

1.2. POLICY.

This manual implements the policies in DoDI 6055.05 by implementing the procedures to:

a. Provide a safe and healthy work environment for all military personnel and DoD civilian employees.

b. Develop and administer occupational medical surveillance programs, in accordance with:

(1) DoD Directive 6490.02E.

(2) DoDIs 6055.05 and 6490.03.

c. Provide occupational medical examinations for:

(1) Medical qualification determinations under Part 339 of Title 5, CFR.

(2) Worker exposures to DoD workplace hazards that may result in adverse health effects for:

(a) Regulated hazards in accordance with Part 1910 of Title 29, CFR.

(b) Hazards that do not have specific medical surveillance programs regulated by the Occupational Safety and Health Administration (OSHA).

SECTION 2: RESPONSIBILITIES 7

SECTION 2: RESPONSIBILITIES

DOD COMPONENT HEADS.

The DoD Component heads establish and maintain OM programs that support assigned personnel, in accordance with:

a. DoDI 6055.05.

b. Parts 293 and 339 of Title 5, CFR.

SECTION 3: OVERVIEW OF MEDICAL SURVEILLANCE AND QUALIFICATION EXAMINATIONS 8

SECTION 3: OVERVIEW OF MEDICAL SURVEILLANCE AND

QUALIFICATION EXAMINATIONS

3.1. PURPOSE.

Occupational medical examinations are performed for two distinct purposes: medical surveillance and medical qualification. Occupational medical examinations are provided only if they are based on the requirements of the duty position (medical qualification) or objective evaluation of potential or actual hazards or exposures (medical surveillance).

a. Medical Surveillance Examinations.

Occupational medical surveillance examinations are performed when exposures may cause employee injury or illness. The goal of occupational medical surveillance is to prevent or minimize adverse health effects by identifying evidence of unexpected exposures or overexposures before they cause harm.

b. Medical Qualification Examinations.

Occupational medical qualification examinations:

(1) Are performed to determine the nature of a medical condition that affects safe and efficient performance.

(2) Result in a medical recommendation to supervisors and human resources (HR) personnel. Supervisors, in consultation with HR personnel, as appropriate, will then decide whether the examinee is placed or retained in a position or separated from employment.

3.2. DOCUMENTATION OF THE EXAMINATION.

a. To improve efficiency, medical surveillance examinations may be performed at the same time as medical qualification examinations. To prevent confusion, providers should be alert to the medical surveillance and medical qualification aspects of examinations when communicating with management and clearly document and distinguish between the purposes for each part of the examination.

b. The OM provider should ensure that the reasons for including each part of the combined medical examination are recorded. As with all medical examinations, the purpose, pertinent history, physical examination findings, and results of studies will be recorded for each OM examination. This is important for the:

(1) Proper performance of the examination and follow-up.

(2) Investigation of abnormalities.

(3) Interpretation of results.

SECTION 3: OVERVIEW OF MEDICAL SURVEILLANCE AND QUALIFICATION EXAMINATIONS 9

(4) Formulation of medical recommendations.

3.3. COMMUNICATION.

a. Examinee.

The examining OM provider must:

(1) Provide examinees with information concerning the unique nature of the provider-examinee relationship for OM examinations compared to the more traditional provider-patient relationship associated with personal health care.

(2) Provide examinees with the purpose of the medical examination, whether that be:

(a) Medical surveillance;

(b) Medical qualification; or

(c) Both.

(3) Inform all examinees of the results of their medical tests and examinations performed as components of the OM examination. For more details, see Paragraphs 4.7.c. and 6.4.d. of this issuance.

(4) Provide examinees with any recommendations for work restrictions that will be made to the HR or supervisory official requesting the examination.

(5) Consider, if the examinee was found “not medically qualified” to perform the duties of the position, or there was a recommendation for a work restriction, any supplementary information the examinee provides from a personal health care provider. The OM provider will evaluate the supplementary information to consider whether the determination or recommendations should be changed.

b. Supervisor or HR Personnel.

The OM provider must:

(1) Provide the supervisor or HR personnel with:

(a) The medical qualification or medical surveillance examination completion status.

(b) Duty status recommendations—including any restrictions, duty limitations, and requirements for using personal protective equipment (PPE) required by Part 1910 of Title 29, CFR.

(2) Notify the supervisor or HR personnel when assistance is needed with identifying the cause of an overexposure to an occupational hazard; and work with industrial hygiene (IH), safety, and the supervisory chain to recommend mitigation measures when an overexposure is

SECTION 3: OVERVIEW OF MEDICAL SURVEILLANCE AND QUALIFICATION EXAMINATIONS 10

suspected or confirmed. Employment of mitigation measures is the responsibility of the supervisory chain.

3.4. REFUSAL TO PARTICIPATE IN EXAMINATIONS.

a. Service Members.

Report any Service member’s refusal or inability to schedule or fully participate in either medical qualification or medical surveillance examinations to the Service member’s chain of command. The report should provide general information regarding the examination status and a recommendation in the absence of examination completion.

(1) Medical Surveillance.

The medical surveillance record should reflect that it is not possible to determine whether the Service member has a detectable adverse health impact from the possible or actual exposures to be evaluated.

(2) Medical Qualification.

The medical qualification record should reflect that it is not possible to determine if the Service member is medically qualified to perform the position duties to be evaluated.

b. Civilian Employees (Appropriated Fund (APF) Governed by Title 5, CFR).

Civilian employees’ participation in an established medical examination program meeting the requirements of Section 339.205 of Title 5, CFR and Part 1630 of Title 29, CFR, whether for medical qualification or medical surveillance, is a condition of employment absent an approved medical or religious exemption. A request for an exemption from those examinations must be reported to the appropriate supervisory official.

(1) Medical Surveillance.

The OM provider should report that the employee did not complete the examination for medical surveillance and that it is not possible to determine whether the employee has a detectable adverse health impact from the possible or actual exposure(s) that were to be evaluated. In addition, notifications to both IH and safety personnel may be appropriate.

(2) Medical Qualification.

(a) Report incomplete medical qualification examinations to the authorized examination-requesting official using an appropriate DoD Component form or the Optional Form (OF)-178, “Certificate of Medical Examination” (available at https://www.opm.gov/forms/pdf_fill/of178.pdf). The authorized examination-requesting official will likely be an HR official or supervisor, in accordance with the policy of the DoD Component concerned.

SECTION 3: OVERVIEW OF MEDICAL SURVEILLANCE AND QUALIFICATION EXAMINATIONS 11

(b) The agency medical officer should inform the authorized examination-requesting individual that the examinee was determined “not medically qualified” and provide an explanation. The explanation must state the reason (e.g., “the examinee has not participated in the examination process”). This information can be reported directly to the authorized examination-requesting official, following DoD Component-specific requirements, stating that the examinee did not:

1. Participate in the examination process—if no part of the examination process was completed; or

2. Complete the examination process—if the examinee began, but did not complete, the examination process.

c. NAF Employees.

NAF employee requirements to participate in medical qualification or medical surveillance examinations are dependent on the applicable DoD Component’s policy. Report an employee’s refusal to participate in examinations to the appropriate examination-requesting official (e.g., “employee has not presented for [or completed] the examination”):

(1) Medical Surveillance.

The medical surveillance record should reflect that it is not possible to determine whether the employee has a detectable adverse impact from the possible or actual exposure(s) that were to be evaluated.

(2) Medical Qualification.

The medical qualification record should state that it is not possible to determine if the examinee is medically qualified to perform the position duties that were to be evaluated.

3.5. PAYMENT FOR MEDICAL EXAMINATIONS.

a. The DoD is responsible for the costs associated with the completion of required elements of medical surveillance and medical qualification examinations. Payment for any testing for non-occupationally related conditions (e.g., diabetes) is the responsibility of the applicant or examinee.

b. The responsibility for following up on abnormal medical test results or examinations, including any associated costs, depends on the purpose of the examination and employment status of the examinee.

(1) Medical Surveillance Examinations.

The DoD is responsible for medical surveillance examinations. This includes the responsibility for following up on abnormal findings related to the medical surveillance examination and any associated costs, until or unless it is determined that the abnormal findings

SECTION 3: OVERVIEW OF MEDICAL SURVEILLANCE AND QUALIFICATION EXAMINATIONS 12

are not job related. For incidental (non-occupational) abnormal findings, employees are responsible for:

(a) Following up with their personal health care provider.

(b) Paying for any associated costs.

(2) Medical Qualification Examinations.

The DoD is responsible for the costs associated with the required, initial medical qualification examination. After the required, initial examination, it is the examinees’ responsibility to follow up on any abnormal findings with their personal health care provider and pay for all associated costs. This includes costs that may arise from the examinee seeking additional information, evaluation, or documentation to be provided to the OM examiner for review and assessment regarding the medical qualification.

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 13

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE

EXAMINATIONS

4.1. OVERVIEW.

This section reviews the overall process for medical surveillance examinations in the DoD. It is not intended to comprehensively cover all aspects of medical surveillance and does not cover all OSHA requirements.

4.2. IDENTIFY EMPLOYEES WITH POTENTIALLY HAZARDOUS WORKPLACE

EXPOSURES.

a. The primary source of information used to identify hazardous workplace exposures are workplace surveys and assessments typically performed by safety and IH personnel. Safety and IH personnel:

(1) Complete workplace assessments, surveys, and job-hazard analyses, in accordance with Part 1910 of Title 29, CFR and DoDI 6055.05.

(2) Identify hazards and hazardous exposures to individual employees and document the survey and assessment information in the Defense Occupational and Environmental Health Readiness System-IH.

b. Personnel contributing to the identification of hazardous workplace exposures include:

(1) Industrial hygienists.

(2) Safety personnel.

(3) OM clinic personnel.

(4) Public health personnel.

(5) Employees.

(6) Supervisors.

c. Determination of an individual employee’s hazardous exposures includes evaluating:

(1) Individual Employee Exposure.

(a) Objective, quantifiable assessment of individual employees’ exposures (e.g., radiation dosimetry, personal air sampling) is the preferred method for identifying employees for medical surveillance. It provides concrete documentation for decision making to consider individuals who require medical surveillance.

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 14

(b) The individual employee exposure assessment characterizes stressors, job demands, and exposure routes and quantifies levels of personal exposure. Since this is an intensive use of IH resources, individual employee exposure assessments are not always available. The National Institute for Occupational Safety and Health (NIOSH) has guidance available for occupational exposure estimation (commonly referred to as “exposure banding”) available at https://wwwn.cdc.gov/Niosh-oeb/. This tool may be used to generate exposure guidance and associated medical surveillance recommendations when no specific occupational exposure information is available.

(2) Job Title.

Job title and description may guide the process of characterizing workplace exposures associated with specific work tasks.

(3) Workplace Exposure.

This grouping assumes that all employees assigned to a workplace performing the same work tasks are exposed to the same level of potential or actual hazard with the same route of exposure.

(a) The parameters for the presumed group’s exposure are based on a worksite characterization, generally completed by IH or safety personnel. This allows for the same estimates of potential or actual health effects to be applied to all employees at the same workplace.

(b) Enrolling employees in an occupational medical surveillance program, based on the assumption that all employees are exposed similarly because of their workplace assignment, should only be done when there is reasonable certainty that the exposure is experienced by all employees.

(4) Similar Exposure Group (SEG).

The SEG is established by IH personnel. Employees who are assigned to the SEG perform similar work tasks. It is possible for a single workplace to have employees who are assigned to multiple SEGs, depending on their assigned tasks. Individual employee exposure characterization is performed on a representative sample of employees within the SEG. Since all employees assigned to a particular SEG perform the same work tasks and have similar exposures (frequency, duration, concentration), any exposure characterization results are assigned to each employee assigned to the SEG.

d. When occupational exposure and hazard information are not available, OM personnel should obtain such information by requesting an IH workplace assessment survey or safety survey.

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 15

4.3. DETERMINE AVAILABILITY OF MEDICAL SURVEILLANCE GUIDANCE FOR

WORKPLACE HAZARDS.

a. Review sources of medical surveillance guidance, including other DoD policies, DoD Component policies, and OSHA policies (available at https://www.osha.gov/SLTC/medicalsurveillance/surveillance.html).

b. Review quality measures (e.g., sensitivity, specificity, positive predictive value, negative predictive value), when appropriate, for the recommended medical surveillance tests. However, not all tests warrant a review of quality measures (e.g., liver function test, complete blood count).

c. Recognize that there may be hazardous exposures where there are no validated medical surveillance guidelines or requirements. In these circumstances, it is necessary to work with supervisors, safety and IH personnel, and the DoD Component OM authority to implement a hazard-based medical surveillance program.

4.4. ENROLL INDIVIDUAL EMPLOYEES IN MEDICAL SURVEILLANCE

PROGRAMS.

The OM provider will:

a. Review available information for each employee (e.g., IH exposure assessment data, worksite safety assessments, required type of examination) and confirm medical surveillance enrollment status (i.e., baseline, periodic, or termination).

b. Determine if there is mandated medical surveillance for employees with particular job tasks or work locations. For DoD civilian employees, this medical surveillance must be established by DoD or DoD Components in compliance with Office of Personnel Management (OPM) requirements in Section 339.205 of Title 5, CFR and Equal Employment Opportunity Commission requirements in Part 1630 of Title 29, CFR.

4.5. IDENTIFY MEDICAL SURVEILLANCE EXAMINATION PROCEDURES.

a. It is important that OM providers develop and follow consistent examination protocols with similar content for employees enrolled in a medical surveillance program.

(1) Ideally, examination protocols will be developed centrally by a DoD Component to encourage consistency and support population-level analysis of occupational injury and illness information.

(2) The Navy and Marine Corps Public Health Center Technical Manual (TM) OM 6260, also known and referred to in this issuance as the “Navy’s Medical Matrix”:

(a) Guides all occupational medical examinations for Navy and Marine Corps personnel.

https://www.osha.gov/SLTC/medicalsurveillance/

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 16

(b) Can be used as a resource by other DoD Components. Note that position titles, job duties, and exposure profiles may differ among DoD Components. Use of the Navy’s Medical Matrix by a DoD Component must follow DoD Component approval procedures.

b. Medical surveillance program elements should be the same for all employees in a particular program, based on the similar factors that led to medical surveillance enrollment, including:

(1) Specific job tasks or requirements.

(2) Workplace risk factors, including exposure to physical, chemical, biological, radiological, and other stressors.

(3) Target organ systems.

(4) Legal and regulatory requirements.

(5) Environmental risk factors (e.g., specific to work location).

(6) Required use of PPE.

c. Individual employee-specific factors may influence medical surveillance examination elements (i.e., additional or substitute tests). These factors may include:

(1) Personal health.

(2) Previous job tasks, requirements, and work history.

(3) Environmental risk factors (e.g., household and hobby exposures).

(4) Allergies.

(5) Use of tobacco, alcohol, and illicit drugs.

(6) Diet.

(7) Use of prescriptions, over-the-counter medications, vitamins, and other supplements.

d. Medical surveillance examinations are focused and relevant to the surveillance program.

Elements of medical surveillance typically include, but are not limited to:

(1) History questions (personal and work history). To comply with Part 1635 of Title 29, CFR, prohibiting discrimination on the basis of genetic history, history questions for DoD civilian employees may not include family history.

(2) Physical examination.

(3) Biological monitoring (testing of body fluids or tissues for the toxic substance itself, a metabolite, or a physiologic change).

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 17

(4) Other laboratory and ancillary tests (e.g., spirometry, audiograms, radiographs, and electrocardiograms (EKGs)).

4.6. PERFORM MEDICAL SURVEILLANCE.

a. Medical surveillance examinations include:

(1) Baseline or Initial Examinations.

Baseline or initial examinations:

(a) Document the employee’s health status for future comparison.

(b) Should be performed:

1. Before the worker starts work with exposures to potential or actual health risks; or

2. No later than 60 days after assignment, unless more stringent requirements exist.

(2) Periodic Examinations.

Periodic examinations are:

(a) Performed to monitor for any health impacts that hazardous exposures may have on an employee during the surveillance period.

(b) Conducted at scheduled, routine intervals. These intervals may be specified by the regulatory authority (e.g., OSHA), DoD or DoD Component policy, or OM best practices.

(3) Termination of Exposure Examinations.

Termination of exposure examinations are performed to assess pertinent aspects of a worker’s health when exposure to the occupational hazard (e.g., the hazard that prompted the medical surveillance) has ceased. Exposure may cease when a worker is reassigned, when a work process or practice changes, or the worker leaves employment. Federal regulations (e.g., Part 1910 of Title 29, CFR) specify termination of exposure examinations for some regulated work activities and occupational exposures to specified hazards.

(4) Situational Examinations.

Situational examinations are conducted in response to a specific incident where a possible overexposure to a hazardous substance is suspected.

(a) Such an incident should prompt an objective determination as to whether:

1. Other employees with suspected overexposure should be examined.

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 18

2. The employee or other employees should be enrolled in medical surveillance.

(b) Due to the situational circumstances, protocols may vary from baseline, periodic, or termination of exposure protocols.

(c) Some OSHA programs (e.g., methylene chloride, cadmium, vinyl chloride, hexavalent chromium, beryllium) require enrollment in occupational medical surveillance following situational exposures.

b. To characterize the status of specific organ systems that could be impacted by the potential or actual workplace exposures covered by the medical surveillance program, the OM provider:

(1) Obtains a focused medical history.

(2) Conducts a pertinent review of individual medical systems.

(3) Performs a targeted physical examination.

(4) Orders pertinent ancillary tests.

c. If an illness or condition is identified during the medical surveillance examination, it may or may not be work related. Certain occupational illnesses suggest the presence of a particular workplace hazard and may indicate a failure of a workplace hazard control. These illnesses are occupational sentinel events. A list of some occupational illnesses that may be encountered in the DoD is presented in Table 1.

(1) Though not an all-encompassing list, Table 1 provides examples of DoD work processes, their associated hazards, and corresponding potential medical conditions.

(2) When any of these medical conditions are identified during a medical surveillance examination, they should be reviewed in the context of relevant workplace exposures and other individual factors (e.g., renal failure may be caused by inorganic mercury from a workplace exposure or by individual factors such as the progression of diabetes and hypertension).

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 19

Table 1. Examples of Medical Conditions Associated with Workplace Overexposure

Medical Condition Industry/Process/Occupation Common Hazardous Agent Acute bronchitis, Janitors, explosives manufacture Ammonia pneumonitis, and pulmonary edema

Swimming pool chlorination, bleach alkali, and Chlorine due to fumes and Arc welders, nitric acid Nitrogen oxides vapors Welders, metal workers, demilitarization Cadmium Acute or chronic renal failure

Firing range workers, solderers, munitions manufacture, corrosion control, radar and sonar (ceramics), batteries

Inorganic lead

Electrolytic processes Arsine Dentists (also used in mercury vapor lamps, silver-zinc batteries, color cartridges, switches, fuses, paints)

Inorganic mercury

Welders, metal workers, demilitarization Cadmium Agranulocytosis or neutropenia

Fuel handlers Benzene Explosives and pesticide workers Phosphorus Pesticides, pharmaceuticals handlers Inorganic arsenic

Aplastic anemia Explosives manufacture Trinitrotoluene Fuel handlers Benzene Radiologists, nuclear reactor workers Ionizing radiation

Asbestosis Shipyard workers, firefighters Asbestos Cancer of larynx Shipyard workers, firefighters Asbestos Cancer of cavities nasal Coating applicators (chrome surface treatments, chromate conversion coatings, certain anodizing processes, and primer paints for metal surfaces)

Chromates

Nickel platers Nickel Carpenters Wood dust

Cancer of nasopharynx

Carpenters (using treated wood), electricians, disinfectant and pesticide handlers

Chlorophenols

Cancer of trachea, Shipyard workers, construction, firefighters Asbestos bronchus, and lung Coating applicators, chrome platers, painters metal Chromates

Nickel platers Nickel Chemical demilitarization workers Mustard gas Pesticide handlers Pesticides, herbicides, fungicides, insecticides Welders, electroplating Arsenic, sulfur dioxide, copper, lead, sulfuric acid, arsenic trioxide Welders, gas cutters, shipyard workers, firefighters

Hexavalent chromium, asbestos

Foundry-floor molders and casters Polycyclic aromatic hydrocarbons Chromate painters Lead chromate, zinc chromate, strontium chromate Lathe operators, metal assemblers workers, machine Mineral and cutting oils

Radiologists, nuclear reactor workers Ionizing radiation Fuel handlers Benzene

Cerebellar ataxia Use of solvents, paints, and adhesives Toluene

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 20

Table 1. Examples of Medical Conditions Associated with Workplace Overexposure, Continued

Medical Condition Industry/Process/Occupation Common Hazardous Agent Chronic beryllium disease

Manufacture of aircraft disc brakes, nuclear weapons and reactors, missile parts, heat shields, x-ray machine parts, mirrors, and spacecraft

Beryllium

Constrictive bronchiolitis

Arc welders, nitric acid, chemical demilitarization workers, food preparation

Nitrogen dioxide, mustard gas, diacetyl

Contact and allergic dermatitis

Use of adhesives and sealants, vehicle building and repair

Irritants (e.g., cutting oils and metal working fluids, phenol, solvents, acids, alkalis, detergents), allergens (e.g., nickel, chromates, formaldehyde, dyes, rubber products)

Extrinsic asthma Cancer chemotherapy, electroplating, windings of high-temperature furnaces, dentistry

Platinum

Polyurethane, adhesives, paint workers Isocyanates Alloy, catalyst, cement workers Chromium, cobalt Solderers Aluminum soldering flux Researchers, pathologists, insulation workers Formaldehyde Nickel platers Nickel sulfate Cooks Flour Medical personnel, first responders (latex glove exposure)

Latex particles

Mesothelioma Shipyard workers, construction, firefighters Asbestos Methemoglobinemia Explosive manufacturers Aromatic amino and nitro compounds

(e.g., aniline, trinitrotoluene, nitroglycerine)

Rubber workers Aniline, o-toluidine, nitrobenzene Parkinson’s disease (secondary)

Welders Manganese Exposure to engine exhaust Carbon monoxide

Raynaud’s phenomenon (secondary)

Use of vibrating tools (grinders, riveters, jackhammers, chain saws, etc.)

Hand and arm vibration

Silicosis Sandblasters, foundry workers, concrete cutters, rock cutters, construction workers

Silica

Toxic encephalitis Munitions workers, electronic equipment workers, foundry workers

Lead

Adhesives and grouts, water and treatment, textile processing waste Acrylamide

Toxic hepatitis Degreaser or solvent for parts cleaning, maintenance of weapons systems, vapor degreaser

Tetrachloroethane, trichloroethylene, tetrachloroethylene

Explosives manufacture Phosphorus, trinitrotoluene Epoxy hardening agents, anticorrosive materials, wire coatings, polyurethane foam

Methylene dianiline

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 21

Table 1. Examples of Medical Conditions Associated with Workplace Overexposure, Continued

Medical Condition Industry/Process/Occupation Common Hazardous Agent Toxic neuropathy Pesticide applicators, pigments and pharmaceuticals formulators Arsenic and arsenic compounds

Degreasing operations Hexane Solvents for adhesives, lacquers, paint removers, acrylic coatings, plastic-coated fabric

Methyl n-butyl ketone

Explosives manufacture Trinitroluene Fungicide handlers Organic mercury Ethylene oxide sterilizer operators, microbiologists, supervisors, inspectors

Ethylene oxide

Adhesives and grouts, water treatment, textile processing and waste Acrylamide

Firing range workers, solderers, munitions manufacture, corrosion control, radar and sonar (ceramics), batteries

Inorganic lead

Dental technicians, surgeons Methyl methacrylate monomer Ulceration of skin or nasal mucosa, perforation of nasal septum

Corrosion control workers, painters, sanders Hexavalent chromium

(3) When clusters of similar exposures or medical conditions occur, that should raise concern and warrant expedited investigation and consultation with IH, safety, and workplace supervisors to assist in evaluating workplace practices, hazards, and appropriate exposure controls.

d. Further investigation may:

(1) Improve the understanding of the impact of potential or actual workplace exposures.

This may include additional medical testing and a workplace visit. The IH staff and supervisory and safety personnel will have, or be able to, obtain information about the exposure(s), type of work activities, and the presence and use of hazard controls in the workplace.

(2) Lead to:

(a) A timelier and accurate diagnosis.

(b) Determining if conditions that were not previously considered work related are now recognized as work related.

(c) Preventing future exposures in the workplace.

4.7. REPORT MEDICAL SURVEILLANCE.

a. Medical surveillance reporting includes documentation of the medical surveillance examination with findings of test results and studies in the employee occupational health (OH)

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 22

record (i.e., the employee medical folder) and appropriate communication to the employee and supervisors.

b. OSHA requires OM surveillance records be maintained for the duration of employment plus 30 years.

(1) Pursuant to Subpart E of Part 293 of Title 5, CFR, OM records for DoD civilian employees must be maintained for the duration of employment plus 30 years or as long as the official personnel file is maintained, whichever is longer.

(2) In the DoD, OM records for NAF employees will follow these same requirements.

c. The content of the employee OH record for DoD civilian employees (i.e., medical folder) will include:

(1) Time and place of the delivery of OM services.

(2) Names(s) of personnel delivering OM services, including:

(a) Full names.

(b) National provider identifier numbers.

(3) Description and results of all services delivered (i.e., history, physical examination, laboratory, and ancillary testing).

(4) Summary statements, delivered in writing or orally, regarding information and recommendations provided to the employee, the supervisory chain, HR, industrial hygienists, safety personnel, or others. Copies of written communications should be retained, when possible, to create a more complete record.

d. The format of the employee OH record may include requirements regarding use of specific forms, whether in electronic or hard-copy format. Hard-copy forms, after completion, should be electronically scanned and uploaded to the electronic OH record, if applicable.

(1) Medical documentation received from an employee should be:

(a) Validated (i.e., the record’s origin by provider, laboratory or organization, date the record was created, and the content is legible).

(b) Included in the employee OH record (i.e., medical folder) to show:

1. Submission by the employee.

2. The origin outside of the OH clinic.

(2) The OM provider should add supplementary evaluations or annotations to the submitted medical documentation, as appropriate.

SECTION 4: GENERAL PROCEDURES FOR MEDICAL SURVEILLANCE EXAMINATIONS 23

e. When an occupational illness is confirmed, it must be recorded in accordance with Part 1904 of Title 29, CFR and DoDI 6055.07.

f. The OM provider must inform each employee of the employee’s medical surveillance examination results following completion of the examination. Information will include:

(1) The significance of work-related hazards in the work environment with an explanation tailored to the nature of exposures, hazards, and health status of the worker.

(2) All medical conditions or other findings that are identified and whether or not the employee is at an increased risk of health impairment from continued exposure to work-related hazards.

(3) Recommended workplace exposure limitations and use of PPE in consultation with IH and safety personnel.

(4) Recommendations to the supervisor or chain of command on the use of appropriate work restrictions, administrative controls, PPE, and engineering controls (e.g., environmental or facilities modifications) to reduce or mitigate employee exposure of the examinee and other employees in consultation with IH and safety personnel.

(5) Recommendation for DoD civilian employees to contact their supervisor and supporting HR office for workers’ compensation claims filing procedures. Workers’ compensation is an HR program in which OM has an important supporting role.

g. Communication with the supervisory or command chain, HR personnel, industrial hygienists, safety personnel, or other management representatives (e.g., facilities managers) must comply with applicable health information privacy protections.

4.8. PREPARE FOR FUTURE MEDICAL SURVEILLANCE EVALUATION CYCLE.

a. All steps described in Paragraphs 4.2. through 4.8. should be re-evaluated upon changes to work practices or the work status of the employee, as determined during routine safety and IH surveys or upon notification of the supervisor. It should not be assumed that work processes, tasks, position assignments, and actual or potential exposures will remain the same.

b. Revalidation may involve requesting updated information (i.e., the previous year’s workplace assessments) to identify:

(1) Hazardous work exposures; or

(2) Changes in employee job titles and functions.

SECTION 5: POSITION- AND TASK-SPECIFIC PROCEDURES FOR MEDICAL SURVEILLANCE

EXAMINATIONS 24

SECTION 5: POSITION- AND TASK-SPECIFIC PROCEDURES FOR

MEDICAL SURVEILLANCE EXAMINATIONS

5.1. OVERVIEW.

This section provides medical surveillance examination requirements that are specific to particular DoD personnel, groups, and exposures. It does not include all OSHA and DoD Component requirements.

5.2. MEDICAL SURVEILLANCE FOR OSHA- AND DOD-REGULATED HAZARDS.

a. Medical surveillance requirements for all OSHA-regulated hazards can be found on OSHA’s website at https://www.osha.gov/SLTC/medicalsurveillance/standards.html. OM providers will follow the requirements outlined for OSHA-regulated hazards and this issuance when conducting medical surveillance examinations, unless there are more protective requirements issued by the DoD or a DoD Component such as the DoD’s blood lead requirement described in Table 2.

b. The OSHA surveillance requirements are the minimum mandatory requirements for medical surveillance. They apply to military personnel and DoD civilian employees, except as otherwise indicated and designated as “military-unique.”

5.3. MEDICAL SURVEILLANCE CONSIDERATIONS FOR REPRODUCTIVE

HEALTH.

a. General.

(1) Reproductive hazards are those stressors that have the potential to adversely affect the reproductive process. Generally, engineering controls, administrative policies, and PPE that protect workers from harmful chemical, biological, or physical stressors will also protect their reproductive health.

(2) OM providers, working with IH and safety personnel, should be familiar with potential reproductive hazards in the work environment so that they can:

(a) Advise supervisors, leaders, and HR personnel about reproductive hazard management.

(b) Provide appropriate examination of, and counseling for, concerned workers.

(c) Communicate with an employee’s personal health care provider if requested by the employee.

EXAMINATIONS 25

b. Additional Policies and Technical Guidance.

DoD Component-specific policies and technical guidance are available to assist the OM providers in providing optimum care for employees in their reproductive years. These references include:

(1) Army Regulation (AR) 40-501.

(2) Department of the Army Pamphlet (DA PAM) 40-11.

(3) Office of the Chief of Naval Operations Instructions 5100.23H and 6000.1D.

(4) Navy and Marine Corps Public Health Center TM-6260.01D.

(5) Air Force Manual 48-146.

c. Medical Surveillance Considerations for Pregnant Workers.

While uncomplicated pregnancy does not necessarily require significant alteration of the work environment, modification of job tasks may be required to create the safest and healthiest environment for the pregnant worker and the unborn child.

d. Medical Surveillance Considerations for Breastfeeding Workers.

While breastfeeding does not necessarily require significant alteration of the work environment, control of environmental exposures and promotion of workplace hygiene can limit the transfer of workplace contaminants into the breast milk.

5.4. MEDICAL SURVEILLANCE CONSIDERATIONS FOR NANOMATERIAL

WORKERS.

a. Description of Nanomaterials.

The term “nanomaterial” only describes the physical property of the material (i.e., having a particle size of less than 100 nanometers in at least one dimension), not its complete physical and chemical makeup or toxicity. The toxicity of nanomaterials may be affected by their physical properties (e.g., influencing absorption), and the chemical form of the particles, routes of entry, and dose of exposure. The exposure profile of nanomaterials may depend on their formulation.

DoD uses aluminum nanoparticles in diesel fuel additives, alloys, and explosives. DoD use in research areas includes nanomaterial use in printed electronics and protective armor.

(1) The sonication, shaking, stirring, pouring, or spraying of powdered nanomaterials can result in inhalation exposure. Nanoparticles that are fixed within a matrix are usually less hazardous until there is mechanical disruption (e.g., grinding, cutting, or burning). In addition to inhalation, nanomaterials may be absorbed through the skin or ingested.

(2) Nanomaterials are found in commercial products and there are no requirements to specifically identify the presence of nanomaterials on labels or safety data sheets. However, EXAMINATIONS 26 awareness of the nanomaterial’s presence is necessary to suitably limit exposure and establish appropriate medical surveillance programs. Supervisors, IH, safety, and logistics personnel can assist the supervisory chain in obtaining risk assessment information.

b. Medical Surveillance.

(1) Currently, there are no Federal or OSHA occupational exposure or medical surveillance requirements for nanomaterials.

(2) There are recommended exposure limits for titanium dioxide, carbon nanotubes, and carbon nanofibers published by the NIOSH. Additional information about occupational exposure, risks, and medical surveillance from nanomaterials is available at https://www.cdc.gov/niosh/topics/nanotech/.

5.5. MEDICAL SURVEILLANCE FOR LASER WORKERS.

a. Medical surveillance is required for personnel working with Class 3b and Class 4 lasers and laser systems; but not required for personnel working with Class 1, Class 2, or Class 3a lasers or laser systems.

b. All laser accidents should be reported through the local safety office in accordance with DoD Component procedures. Consult DoDI 6055.15 for information on reporting exposures to the DoD Laser Injury Hotline.

c. Laser workers must have an ocular and visual history, visual acuity, and central visual fields test (via an Amsler grid or similar macular integrity test) as part of baseline (preplacement) and termination examinations. Visual acuity and central field tests must be performed on each eye separately.

(1) No further examination is required if the medical history is normal for the eyes and the visual acuity is adequate for the job. Central visual fields are deemed normal via an Amsler grid test or similar macular integrity test.

(2) Medically significant departures from normal limits must be evaluated to determine the reason and potential duty limitations. This may be done by ocular funduscopic examination or other tests, as deemed appropriate by the eye care professional (i.e., optometrist or ophthalmologist), OM provider, or flight surgeon. Baseline funduscopic photography may be useful for documenting the retinal status but is not part of routine, laser surveillance.

d. Incidental laser workers do not require any medical surveillance unless the supervisor or supporting OM provider, based on the worker’s medical history, determines that selected baseline examinations or tests are appropriate.

EXAMINATIONS 27

5.6. MEDICAL SURVEILLANCE FOR WORKERS EXPOSED TO

ELECTROMAGNETIC FREQUENCY RADIATION.

Medical surveillance is required for personnel working within electromagnetic frequency radiation fields as specified in DoDI 6055.11.

5.7. MEDICAL SURVEILLANCE FOR PEST MANAGEMENT PERSONNEL.

a. Medical Surveillance for Personnel Who Work with Cholinesterase-Inhibiting Pesticides.

(1) Cholinesterase testing is the most important tool in the medical surveillance of workers who use cholinesterase inhibiting pesticides. To oversee reliability of test results for a given individual, serial cholinesterase monitoring should be performed in the same laboratory using the same analytical method, whenever possible. Establishing an individual’s baseline (pre-exposure) value for both plasma and red blood cell (RBC) cholinesterase activity is essential for medical monitoring and supervision. All subsequent monitoring results must be interpreted as a percentage of the individual’s baseline value.

(2) Depression of an employee’s cholinesterase, either plasma or RBC, should be investigated. Plasma and RBC cholinesterase can be depressed in the absence of chemical inhibition. About three percent of the population has a naturally low level of plasma pseudo-cholinesterase that is genetically determined.

(a) Individuals with hepatitis, cirrhosis, malnutrition, chronic alcoholism, and dermatomyositis exhibit low plasma cholinesterase activities. Cocaine, carbon disulfide, benzalkonium salts, organic mercury compounds, ciguatoxins, solanines, pregnancy, birth control pills, and metoclopramide may also depress the plasma cholinesterase level.

(b) Plasma cholinesterase (also commonly referred to as “pseudo-cholinesterase”) is more labile than RBC cholinesterase and, therefore, is less reliable in reflecting actual enzyme depression at neuro-effector sites. It is generally more rapidly inactivated by exposure to organophosphates. Since plasma cholinesterase is produced in the liver, it can be regenerated relatively quickly, compared to RBC cholinesterase. After mild exposure, there is sometimes a rebound phenomenon resulting in elevated levels of plasma cholinesterase.

(c) RBC cholinesterase (also commonly referred to as “true cholinesterase”) is biochemically the same enzyme as the acetylcholinesterase located at the neuro-effector cell synapses.