fd-966.pdf

FD-966 (Rev. 5-16-2008) 67 Number:_________________________

FBI Diver – NOAA Diving Medical Evaluation Criteria

To:

From: FBI Field Office

Examinee: _______________________________________________ D.O.B. __________________

Job Position: ____________________________________

Appointment Date: __________________ Time: _______________

Bring all shot records (CDC –731, International Certificate of Vaccination)

VENDOR USE THIS FORM PLUS FD-943, FITNESS FOR DUTY PERIODIC EXAM FORM

CPT Codes Required Core Components

81001 Required Urinalysis

82270 Offer Stool for occult blood X 3

92551 Required Audiometry

99172 Required Distant & near visual acuity with and with out corrections

99172 Required Visual fields, strabismus

99172 Required Color vision

99395, 96, 97 Required History, PE, vitals (ht, wt, B/P, pulse, resp, temp) , written summary of findings

71020 Required Chest x-ray, P/A and lateral

FD-899, FD-900 Required OSHA resp quest and& MD SCBA approval

93000 Required EKG, 12 lead /w interpretation

85025 Required Complete Blood Count with diff

94010 Required Pulmonary Function test

Update as required Review Basic Immunization Series

90658 Update as required Influenza, annually

90718 Update as required Tetanus/diphtheria q 10 years or use Tdap as below

90715

Update as required Tdap: tetanus / diphtheria/ pertussis q 10 years

REQUIRED PROVIDER TO USE NOAA ATTACHMENT WITH PE

REQUIRED PROVIDER TO REVIEW DIVE STANDARDS

NOAA DIVING MEDICAL EVALUATION CRITERIA

Keyed to Standard Form 93 (Rev. Jul 1996)

Report of Medical History

These criteria are to be filled out before your appointment. The form is to be given to the physician at the time of the physical exam, along with the other forms. These criteria are to be used by the examining physician in their evaluation of an applicant’s fitness for SCUBA diving. Items indicated as required shall be completed (filled out and addressed in the exam and indicated on the form.) Please write legibly.

1. Name – Required

2. SSN/ID Number – Required

3. Grade – Optional

4. Home Address – Optional

5. Examination Facility – Required

6. Purpose of Examination – Required

7. Statement of Examinee’s present health and medication currently used – Required

8. Occupation – Required

9-24 Self-Assessment of Medical Conditions – Required, Complete as applicable

25. Physician’s summary and comment on all positive answers in items 9 – 24. Primary Care

Provider’s (Physician’s) signature and date required.

NOAA DIVING MEDICAL EVALUATION CRITERIA

Keyed to Standard Form 88 (Rev. 10-94)

Report of Medical Examination These criteria are to be used by the examining physician in evaluating an applicant’s physical fitness for SCUBA diving. Items indicated as required shall be completed (addressed in the exam and indicated on the form.)

1. Name – Required

2. ID Number – Required

3. Grade, Component or Position – Complete as Applicable

4. Home Address – Optional

5. Emergency Contact – Required

6. Date of Birth – Required

7. Age – Required

8. Sex – Required

9. Relationship of Contact – Complete as Applicable

10-15. Birthplace, Agency, Unit, Time of Service, Name of Examining Facility/Address – Required

16. Purpose of Exam, Indicate: Diving – Initial, Annual, etc.)

17. Clinical Evaluation: The applicant should be free of chronic disabling disease or disability. His/her history should be free of disease or disability of the type which could recur under diving conditions or strenuous physical activity. Any disease which might prevent active exercise should disqualify the applicant. There should be no bleeding tendency. Items A-CC required unless otherwise stated. Check each item in appropriate column; enter “NE” if not evaluated. Describe every abnormality in detail. Enter pertinent item number before each comment.

A. Head, Face, Neck, Scalp

B & C Ears General (Internal Canals) and Drums (Perforation). Individuals with acute or chronic ear infection should not dive. Scarring from otitis is not a contraindication to diving. Individuals with perforation of the drum should be disqualified. Healed perforations of the drum of at least two (2) months duration will not be disqualifying. Acute or chronic otitis external with discharge or moderate amounts of cerumen in the external canal should be considered harmful in diving until the canals are clear. Check tympanic movement with Valsalva.

There should be no disease of the mastoids or disturbances in equilibrium.

D & E Nose and Sinuses. Persons having acute or chronic sinus trouble should not dive unless free drainage of sinuses is assured. Congestion, secondary to upper respiratory infection or hay fever, is a contraindication to diving until free passage of air is possible. Persons with acute upper respiratory infection may be passed, but should be strictly cautioned against diving until the upper respiratory infection has completely cleared.

F. Mouth and Throat Bridgework or dentures should fit solidly. The applicant should be capable of retaining a diving mouthpiece. Acute infectious diseases of the soft tissue or the oral cavity are disqualifying until remedial treatment is completed.

G – J Eyes, Visual Acuity, Opthalmoscopic, Pupils, Ocular Motility. A normal ophthalmoscopic and extraocular musculature examination shall be given. Although vision for distant objects under water is often decreased by particulate matter in the water, and the low levels of illumination that may be encountered, the refractive changes introduced by the water environment enlarge objects by about one-fourth. The examining physician and the Fleet

Diving Officer should, in each instance, determine whether the applicant’s visual status is compatible with safety during diving. The following criteria may be helpful as a guide in rendering this decision:

a. Individuals with uncorrected vision of 20/50 or better for near and distant in one or both eyes, and with no evidence or organic ocular disease are unrestricted;

b. Individuals with uncorrected visual acuity of 20/50 to 20/100 for distance and the equivalent of 20/50 or better for near in one or both eyes, and with no evidence or organic ocular disease, may dive if the applicant is advised of the risks associated with the restricted vision;

c. Applicants with uncorrected vision of less than 20/100 for distance and less than 20/50 for near, in one or both eyes, and with no evidence of organic ocular disease should be restricted from diving unless optical correction worn under water improves vision to 20/100 or better for distance and 20/50 or better for near, in one or both eyes. These individuals should be advised of the risks associated with decreased vision;

d. Applicants with significant organic ocular disease affecting both eyes should be restricted from diving;

K. Lungs and Chest Persons with evidence of chronic lung disease, interference with free air passage, or with poor gas exchange should be disqualified. Any active asthma or treatment for asthma within two (2) years will disqualify an individual for diving. Chronic pulmonary diseases including tuberculosis, a history or spontaneous pneumothorax, or a throacotomy shall disqualify the applicant. Pulmonary function or Spirometry testing is indicated for the initial physical only or in the presence of clinical concern.

L. Heart Thrust, size, rhythm, and sounds should be normal. Any clinical evidence suggesting possible cardiovascular disease shall lead to a complete cardiovascular evaluation.

M. Vascular Peripheral vascular disease which might interfere with gas exchange in an extremity should disqualify the applicant. Varicose veins or hemorrhoids should be minimal, absent, and asymptomatic. Vascular examination should reveal no evidence of pain, edema, trophic changes, or impaired deep venous circulation.

N. & Q Gastrointestinal – Persons having symptomatic, acute or chronic gastrointestinal disease, including ulcers, shall be disqualified.

O. & P Prostate & Testicular Complete as applicable

R. Endocrine – Endocrine disturbances including diabetes-requiring medication shall disqualify the applicant.

S. – X G-U System, Upper & Lower Extremities, Feet, Spine, Identifying Body Marks, Scars, Tattoos, Required

Y. Skin, Lymphatics The skin should be free of active, acute, or chronic disease, which may prove undesirable.

Z – AA Neuropsychiatric Neuropsychiatric disturbances may disqualify the applicant. This area is obviously most difficult to evaluate. If the response of the patient to stress is questionable, seriously consider disqualifying him/her. Emergencies below the surface require cool judgment. The alternative is death, perhaps, for other.

Emotional immaturity or instability and recklessness are serious liabilities, not only for the person contemplating diving, but also for his companions. Anyone exhibiting poor temperament should be disqualified. Claustrophobia, as well as other phobias, inability to tolerate facemasks, accident proneness, etc., should be included as poor temperament. Screen for history of headaches, dizziness, fainting spells, soaking sweats, dyspnea, palpitations, stuttering, attempted suicide, sleepwalking, disciplinary problems, Elicit feeling about: living in a restricted environment; possibility of bodily harm; lack of privacy; separation from home and family. Observe appropriateness of emotional reactions during examination.

BB. – CC Breasts, Pelvic, Complete as Applicable

18. Dental Complete as Applicable

19A. Urinalysis Required Attach lab results with physical

19B. Chest X-ray Since pressure related effects are mediated through the respiratory system, and lethal consequences may ensue, a report shall be attached for a 14 x 17 chest x-ray, PA and lateral taken;

1. As a baseline on the initial physical examination.

2. Whenever indicated by medical history or clinical findings.

19C. Serology – Optional

19D. EKG A baseline normal resting 12-lead electrocardiogram shall be performed on the initial examination.

The electrocardiogram shall be repeated every exam age 40 and older. Attach trace and interpretation.

19E. Blood Type and RH Factor Optional on initial exam. Lab results either transcribed or attached.

19F. Other Tests; Hemoglobin or Hematocrit (Required), Spirometry (required initial exam only), Lipid screen

(age 40 and older), and Glucose screen (age 40 and older). Results should be within normal limits. Results shall be attached.

20-21. Height, Weight and Measurements Required Measurements consist of circumference (in inches) the neck, hips (women), waist (women), and abdomen (men). Transcribe measurements in section 42. Notes. Standards are outlined in NC regulation chapter 3, appendix IV titled “Height/Weight Scale for Men and Women”.

22-25. Color Hair, Color Eyes, Build, Temperature Required

26. Blood Pressure Blood pressure should not exceed 145 millimeters systolic, or 90 millimeters diastolic on repeated examinations for unrestricted diving. An applicant who has an elevated blood pressure which is controlled with diet, salt restriction, exercise, or diuretic medication, and who demonstrates no clinical and organ disease may be certified for diving. In this case, the blood pressure should be recorded three times per week for one (1) month by a competent trained observer. If the blood pressure is then within a predominantly normal range, the individual may be granted diving certification.

26A. BP Sitting Required

27A. Pulse, Sitting Optional

27B – E Pulse, Recumbent, Standing, After Exercise. Complete as Applicable

28 – 30 Distant Vision, Refraction, Near Vision Required

31 – 38 Heterophoria, Accommodation, Color Vision, Depth Perception, Field of Vision, Night Vision, Red Lens

Test, Intraocular Tension, Hearing Optional

40. Audiogram Tracing Optional Results shall be in a quantitative format and either attached or transcribed to the physical.

41. Neuromuscular All abnormalities to be noted. The applicant should be able to demonstrate fine and gross muscular coordination. Reflexes should be normal. Joints should be free from disabling arthritic conditions.

Chronic recurrent orthopedic or rheumatologic pathology shall disqualify the applicant.

Vital nerves, deep tendon reflexes, balance, position discrimination, sensation or coordination (including gait), should be recorded in detail. (See 17.Z and 17.AA.).

42. Notes and Significant or Interval History: Required

Has the individual experienced diving related injury.

Assess Central Nervous System: History of syncope, epilepsy, convulsions, organic disease of the central nervous system or history of head injury with sequelae shall disqualify the applicant. Transcribe measurements as described in 20 – 21.

43. Summary of Defects and Diagnoses: Required

Pregnancy Pregnancy will disqualify applicant because of the adverse effects of diving on the fetus.

Alcoholism Unusual use of drugs, medicine, intoxicants, or drug dependence shall disqualify the applicant.

44 – 45 A&B Recommendations Complete as Applicable

46. Check appropriate box and state “For Diving Duty”, Required

47. Complete as Applicable

48-49 Primary Care Provider Signature – Physician, Physician Assistant Required on SF-88 and SF-93

50-51 Complete as applicable