fd-995.pdf

FD-995

Revised

07-06-2006

FEDERAL BUREAU OF INVESTIGATION

EXIT EXAM CHECKLIST FOR HAZMAT TEAM PARTICIPANT

Name ________________________________________________ FBIHQ/Field Office _____________________________

Position __________________________________________

DOB ____________ Date of Physical _________________ SSN _____________________________

Telephone# _______________________________________ On Medical Mandate G Yes G No

Please place a check mark before each item to ensure completeness of physical. If any items/tests are omitted, obtain results before submitting to FBIHQ. Send a completed FD 277, HMRU physicians report, HMRU checklist, the respiratory questionnaire and the original physical exam report to the Fitness-for-Duty, Health Care Programs Unit, Room 6344. Please, be sure to address any known exposures during their time as a HAZMAT Team member. Please be sure to note any/every known exposure that occurred during their time as a HAZMAT Team member, on the SF-88, in # 42.

REPORT OF MEDICAL EXAMINATION (SF-88 Rev.4/94)

G Questions 1 through 16 (by employee) G Section 18 through 42 (by physician) G # 43 Summary report by examiner G Rectal exam->40 year old males ONLY G # 46 Fit for world-wide duty (WWD) G # 19d EKG with interpretation (upon request) G # 48 Signed by examiner G # 20 Height G # 21 Weight G CBC with differential G # 26 & 27 Blood pressure & pulse G Blood Chemistry G # 28 Dis tant vision (corr. & uncorr.) G Blood lead G # 30 Near vision (corr. & uncorr.) G Hemoccult (3 slides) G # 33 Color vision (type & test results) G Urinalysis G # 38 Intraocular Tension (IOT) (>40 years) G Plasma Cholinesterase at Phase I G # 40 Audio-(500hz-8000hz) G RBC Cholinesterase at Phase I G # 42 Employee exposure note (required)

OTHER TESTS

G Exercise Stress Test-(AGENTS ONLY) at age 40, 44, 48, 50, and every two years after age 50 G Spect Thallium or stress (only if approved by HQ)

REPORT OF MEDICAL HISTORY (SF-93)

G Completed by examinee G Elaboration of pertinent data by examiner

FORM FD-300 REQUIRED FOR CLEARANCE FD-900

G Completed & signed by examiner G Respiratory medical evaluation questionnaire

G Physical activities sheet completed & signed by examiner

MANDATORY TESTS

G Chest x-ray (CXR) PA and Lateral G Pulmonary Functions Test-(PFT)-with interpreted report G Mantoux T.B. test-with interpreted report (date given, date read, size of induration read in millimeters) G Copy of PHS-731 International certification, Immunizations

REVIEWED BY: ______________________________________________ TITLE: _____________________________________

DATE: ______________________