| We expect that the client who is having a physical exam be scheduled for a reasonable amount of time with the examiner and in a medical setting. This time should include a full explanation of all lab, test and exam results, a comprehensive physical exam and an opportunity for the Federal Employee to get any questions answered. Employees are to receive copies of any tests or reports as requested. | | | |
| Any employee who has a life-threatening condition or serious finding requiring urgent evaluation or intervention must be notified by the vendor as soon as the serious finding is noted. | | | |
| Examiners shall be currently licensed to practise in the State of Florida. | | | |
| Please indicate all of the professionals below who may be performing an exam: | | | |
| Certified Nurse Practitioner______ Certified Physician's Assistant_____ Physician_______ | | | |
| Originals of all USDA forms and all test results are to be sent within two weeks of the date of the exam to the Reviewing Medical Officer: Lee Wugofski, MD, MPH, 90 Seventh St, Room 4-310, San Francisco, CA, 94103-6705. | | YES_______NO______ | $____________ |
| ATTACHMENT 1 | | | |
| SPECIFIC EXAM COMPONENTS | | | |
| AUDIOMETRY, Using AAOHN Standards | | YES_______NO______ | $____________ |
| Audiometric tests must be conducted with equipment that meets the specifications of, and is maintained and used in accordance with ANSI Specifications for Audiometers S3.6-1969 | | | |
| Pulsed-tone and self-recording audiometers must meet the requirements specified in 29 CFR 1910.95 Appendix C | | | |
| Required frequencies to be tested are 500, 1000, 2000, 3000, 4000, 6000 & 8000 Hertz. | | | |
| "Screening audiograms" e.g. testing only at 15 or 25 dB are not acceptable. True hearing thresholds must be obtained at all frequencies. | | | |
| Copy of the audiometer printout to be sent to the Reviewing Medical Officer. | | | |
| CHEST X-RAY (PA) INCLUDING INTERPRETATION | | YES________NO______ | $_____________ |
| A chest x-ray should be done if so indicated on an employee's Form 182E (Medical Exam Instruction Sheet) or for an employee who has severly decreased Pulmonary Function Tests, is Short of Breath or is symptomatic. | | | |
| Copy fo the Chest x-ray report to be sent to the Medical Reviewing Officer | | | |
| EKG-RESTING | | YES________NO______ | $_____________ |
| A 12-lead EKG may be ordered on an employee's Form 182E (Medical Exam Instruction Sheet) | | | |
| Copy of the result to be sent to the Reviewing Medical Officer. | | | |
| RESPIRATOR MEDICAL CLEARANCE (RMC) | | YES________NO______ | |
| The RMC is the responsibility of the local vendor. The Medical Review Officer does not make RMC decisions. RMC is not standardized through the country. The vendor should follow their own policies and OSHA standards. | | | |
| Please itemize costs for RMC: | Item | | |
| | | $____________ |
| | | $____________ |
| | | $____________ |
| | | $____________ |
| | | $____________ |
| The employee will provide Form GNVRP Request for RMC at the exam. The completed form shall be given to the employee at the conclusion of the exam. Neither this form nor any RMC results are to be forwarded to the Reviewing Medical Officer. | | | |
| ATTACHMENT 2 | | | |
| SPIROMETRY | | YES________NO______ | $____________ |
| NIOSH standards applied. Clinical Standard including FVC, FEV/FVC ratio. Refer to applicable sections of 29 CFR 1910. | | | |
| Best three curves to be printed out. Results to be expressed as observed, predicted and percent of predicted. | | | |
| Copy of results including test curves to be sent to Medical Reviewing Officer | | | |
| VISUAL ACCUITY | | YES________NO______ | $____________ |
| Includes near and far vision with glasses or contacts. | | | |
| Includes color vision and peripheral vision. | | | |
| Copy of results including test curves to be sent to Medical Reviewing Officer | | | |