A07_Medical_Screening_Form.pdf

Exhibit 1 – Sample Medical Questionnaireiii

Fax To: From:

Fax: Pages:

Phone: 6 Date:

Re:

CC:

Comments

My completed Civil Emergency Medical Screening Packet and additional information, if necessary, is included in this fax.

After you have completed your review, please fax the Physician Medical Clearance Memorandum to my home duty station Emergency Operations Center.

My home duty station is _____________________ .

My EOC can be reached by fax at _____________________ or by telephone at _____________________.

If you have any questions regarding the information provided, I can be contacted at _____________________.

If you cannot locate me, please contact my supervisor, _____________________, at _____________________.

Thank you, [BEGIN] MEDICAL SCREENING QUESTIONNAIRE

Complete this Civil Emergency Medical Screening Packet according to the attached instructions. Your civil emergency deployment status is dependent on the Medical Provider receiving ALL the required information. Double Check! It is important to complete this information to the best of your ability. Our primary goal is to ensure that you can perform the job tasks assigned while working long hours under stressful and sometimes physically demanding working conditions without jeopardizing your health.

Section I. Personal Identifiers The following Personal Identifiable Information (PII) is required in order to process your Civil Emergency Medical Screening Packet. All data is subject to HIPAA and Privacy Act requirements and is stored in a secure, encrypted format. Any changes made to your auto-populated data on this form will *not* be reflected back to your Personal Data Sheet (PDS).

*1. ENGLink User ID:

*2. Last Name:

*3. First Name:

*4. Middle Initial:

5. Social Security:

*6. Date of Birth (DD-Mon-YYYY):

7. Office Symbol:

8. Supervisor Name:

9. Supervisor Phone:

10. Telephone Numbers

*11. Telephone (Work):

12. Telephone (Home):

13. Telephone (Cellular):

14. Telephone (Pager):

Section II. Duty Description You may choose only one of the following Civil Emergency Operations position descriptions. The qualifications for your chosen deployment will be determined by the information you supply in the proceeding sections.

Note: FIELD DEPLOYMENTS must be selected if you wish to deploy OCONUS.

*1. FIELD DEPLOYMENTS: Are you requesting a medical clearance for Field work? Field work is primarily conducted outdoors at a CONUS or OCONUS disaster site such as that performed by a Debris Quality Assurance Inspector, Construction Representative, et. al.

Yes No

*2. OFFICE DEPLOYMENTS: Are you requesting a medical clearance for Office work? Office work is conducted primarily in an office setting at a State, Division, or District EOC, ROC, DFO, RFO, or EFO.

Yes No

Section III. General Information Please answer the following questions regarding prior deployment experience and general physical ability.

*1. Are you taking any medications or prescription drugs? If Yes, you must describe in full.

*2. Has your doctor restricted you from performing certain activities? If Yes, you must describe in full.

3. Do you have any condition that would...

*3a. Interfere with your ability to evacuate a site during an emergency? If Yes, you must describe in full.

*3b. Make you prone to sudden incapacitation? If Yes, you must describe in full.

*3c. Be aggravated by significant exertion? If Yes, you must describe in full.

Yes No

*3d. Interfere in any way with the full performance of emergency duties? If Yes, you must describe in full.

Yes No

*4. Have you ever been denied deployment to emergency response operations due to medical condition? If Yes, you must describe in full.

Yes No

*5. Have you ever been sent home from emergency response operations due to a medical condition? If Yes, you must describe in full.

Yes No

*6. Are you currently pregnant? If Yes, you must include a medical release form from your obstetrician with this completed questionnaire to the USACE Medical Provider @ 202-223-6525 (Fax).

Section IV. Medical History Please answer the following questions related to your past medical history and current medical conditions, if applicable.

*7. Do you have an active case of a communicable disease e.g. tuberculosis, chicken pox? If Yes, you must describe in full.

Yes No

*8. Do you bleed excessively after injury or tooth extraction? If Yes, you must describe in full.

Yes No

*9. Do you wear a leg brace, back brace, back support, or any other type of brace? If Yes, you must describe in full.

Yes No

*10. Have you been told within the past year that you have an abnormal EKG? If Yes, you must describe in full.

Yes No

*11. Do you have swollen or painful joints? If Yes, you must describe in full.

Yes No

*12. Do you have dizziness or fainting spells? If Yes, you must describe in full.

Yes No

*13. Have you had an asthma attack within this past year? If Yes, you must describe in full.

Yes No

*14. Have you ever been hospitalized for asthma? If Yes, you must describe in full.

Yes No

*15. Do you have shortness of breath? If Yes, you must describe in full.

Yes No

*16. Do you have pain or pressure in chest? If Yes, you must describe in full.

Yes No

*17. Do you have palpitations (flutter or pounding heart beat)? If Yes, you must describe in full.

*18. Do you have high or low blood pressure? If Yes, you must describe in full.

Yes No

19. If you do have high or low blood pressure, is it well controlled? If Yes, you must describe in full.

Yes No

*20. Do you have a history of heart attack or stroke? If Yes, you must describe in full.

Yes No

*21. Do you have cramps in your legs? If Yes, you must describe in full.

Yes No

*22. Have you been told that you have a hernia? If Yes, you must describe in full.

Yes No

*23. Do you have any life-threatening allergic reaction e.g. bee sting, shellfish or medications?

If Yes, bring your Epi-pen with you on your deployment.

Yes No

*24. Are you currently being treated for depression? If Yes, you must describe in full.

Yes No

*25. Are you currently suffering from depression or excessive worry? If Yes, you must describe in full.

Yes No

*26. Are you currently being treated for any current illness? If Yes, you must describe in full.

Yes No

*27. Have you been hospitalized or had surgery within the past year? If Yes, you must describe in full.

Yes No

*28. Are you currently using any medications that may make you sleepy or reduce your level of attention during working hours? If Yes, you must describe in full.

*29. Are you currently using any medications that require refrigeration? If Yes, you must describe in full.

*30. Are you diabetic? If Yes, please answer questions #31 and #32.

Yes No

31. Do you take insulin? If No, you must describe in full.

Yes No

32. Do you take medication by mouth for elevated blood sugar? If No, you must describe in full.

Yes No

*33. Do you have any history of any seizure disorder? If Yes, please answer question #34.

Yes No

34. Are your seizures controlled? If No, you must describe in full.

Yes No

*35. Are you taking Anticoagulants (blood thinner)? If No, you must describe in full.

Yes No

*36. Do you have migraines or severe headaches? If Yes, you must describe in full.

Yes No

*37. Do you have any gastrointestinal disorder or disease? If Yes, you must describe in full.

Section V. Physical Capacity - OFFICE Work Complete this section only if you have selected to be cleared for Office-only deployments.

*38. Can you perform light lifting (up to 15 lbs.) associated with office tasks on a regular basis without pain? If No, you must describe in full.

Yes No

*39. Can you perform light carrying (up to 15 lbs.) associated with office tasks on a regular basis without pain? If No, you must describe in full.

Yes No

*40. Can you reach above your shoulders and work comfortably? If No, you must describe in full.

Yes No

*41. Can you use the fingers on both hands comfortably? If No, you must describe in full.

Yes No

*42. Can you walk/stand up to perform normal office functions on a daily basis without pain? If No, you must describe in full.

Yes No

*43. Can you kneel without pain? If No, you must describe in full.

Yes No

*44. Can you use your legs to climb up steps on a daily basis without pain? If No, you must describe in full.

Yes No

*45. With or without corrective lenses, are you able to read a typewritten letter at arms length? If No, you must describe in full.

Yes No

*46. With or without the aid of corrective lens is your vision at least 20/20 in one eye and at least 20/40 in the other? If No, you must describe in full.

Yes No

*47. With or without the use of hearing aid(s), can you hear normal conversational speech? If No, you must describe in full.

*48. Can you tolerate excessive heat and humidity (typical Florida summer weather)? If No, you must describe in full.

Yes No

*49. Can you tolerate excessive cold (temperatures less than 4 degrees C / 40 degrees F)? If No, you must describe in full.

Yes No

*50. Can you perform your normal job duties without fatigue? If No, you must describe in full.

Yes No

*51. Are you able to work closely with others under stressful conditions? If No, you must describe in full.

Yes No

*52. Are you able to work alone and away from your normal routine? If No, you must describe in full.

Yes No

*53. Are you able to work protracted or irregular hours away from your home? If No, you must describe in full.

Section VI. Physical Capacity - FIELD Work Complete this section only if you have selected to be cleared for Field deployments, which may include Office work. This section must be completed if you intend to deploy OCONUS.

*54. Do you have complete use of your arms and legs? If No, you must describe in full.

Yes No

*55. Can you perform light lifting (under 15 pounds) on a regular basis without pain? If No, you must describe in full.

Yes No

*56. Can you reach above your shoulders and work comfortably? If No, you must describe in full.

Yes No

*57. Can you reach below your knees and work comfortably? If No, you must describe in full.

Yes No

*58. Can you use your fingers on both hands comfortably? If No, you must describe in full.

Yes No

*59. Can you walk/stand up to four (4) hours daily? If No, you must describe in full.

Yes No

*60. Can you kneel without pain? If No, you must describe in full.

*61. Can you use your legs only to climb (e.g. hills or steps) for up to 1 hour without pain? If No, you must describe in full.

Yes No

*62. Can you climb using your legs or arms to safely work on ladders or scaffolding? If No, you must describe in full.

Yes No

*63. Can you work at heights, below ground, or in confined spaces (tunnels/basements)? If No, you must describe in full.

Yes No

*64. Can you work in a noisy environment using hearing protection? If No, you must describe in full.

Yes No

*65. Can you work outside, exposed to the weather, nuisance dust and air pollutants? If No, you must describe in full.

Yes No

*66. Can you wear personal protective equipment such as respirators and protective clothing? If No, you must describe in full.

Yes No

*67. With or without corrective lenses, are you able to read a typewritten letter at arms length? If No, you must describe in full.

Yes No

*68. With or without the aid of corrective lens is your vision at least 20/20 in one eye and at least 20/40 in the other? If No, you must describe in full.

Yes No

*69. With or without the use of hearing aid(s), can you hear normal conversational speech? If No, you must describe in full.

Yes No

*70. Can you tolerate excessive heat and humidity (typical Florida summer weather)? If No, you must describe in full.

Yes

*71. Can you tolerate excessive cold (temperatures less than 4 degrees C / 40 degrees F)? If No, you must describe in full.

Yes No

*72. Can you perform your normal job duties without fatigue? If No, you must describe in full.

Yes No

*73. Are you able to work closely with others under stressful conditions? If No, you must describe in full.

Yes No

*74. Are you able to work alone and away from your normal routine? If No, you must describe in full.

Yes No

*75. Are you able to work protracted or irregular hours away from your home? If No, you must describe in full.

Yes No

*76. Do you have a current valid drivers license? If No, you must describe in full.

Yes No

*77. If Yes to # 76, does your license have any restrictions?

SECTION VII. Employee Consent PRIVACY ACT NOTICE: This information is provided in accordance with the requirements of the Privacy Act of

1974. (See AR 340-21.)

AUTHORITY: 5 USC 3301, 33 USC 701n, 42 USC 5121 et. Seq., E.O. 9397. System notices A0690-200TAPC, Army Civilian Personnel Systens; OPM Govt 1, General Personnel Records; OPM Govt 10, Employee Medical File System Records. Collection is also addressed in ER690-1-321, Staffing for Civilian Support to Emergency Operations. The purpose for collecting information in the Medical Data Sheet (MDS )is to allow the Medical provider to review your medical condition to ensure that you can perform the job tasks assigned while working long hours, under stressful and sometimes physically demanding conditions without jeopardizing your health. Emergency Managers will use the Medical provider clearance determination to assign tasks and manage staff during deployment to emergency events.

Providing information in the MDS strictly voluntary. If you fail to provide the information the Medical provider will not be able to evaluate your medical condition and you may not be selected for deployment.

PURPOSE: The medical screening questionnaire, interviews, data obtained from tests, review of existing records and review by a medical professional is utilized to determine whether assigned or volunteer employees have any health problems that would prevent them from deployment to, or adversely impact their assigned duties at, emergency response sites. The medical information collected will be filed with other medical record information in the employee's medical file (EMF).

ROUTINE USE: Information may be shared with other Federal agencies such as OSHA and FEMA and state and local agencies for law enforcement, and occupational and/or public health purposes.

DISCLOSURE: Providing this information is voluntary. However, refusal to provide the information requested, including medical information and social security number, may result in the employee not being deployed to perform emergency response assignments at emergency response sites.

[END] MEDICAL SCREENING QUESTIONNAIRE

I certify that I have reviewed the information I have supplied, it is true and complete to the best of my knowledge, and that I have read the Privacy Act Notice assigned to the use of this information.

Write Name in Full

Sign Name in Full

Date

THRU:

ADDRESS:

PHONE/FAX:

US Army Corps of Engineers, District/Division/FOA ATTN: Emergency Operations Center

HQ, US Army Corps of Engineers GAO Building, Room 3J50 441 G Street, NW Washington, DC 20314-1000

202-761-0378 & 8025

THRU: Chief, Safety and Occupational Health Office

THRU:

Supervisor Name:

Supervisor Office Symbol:

Supervisor Phone Number:

TO:

U-PASS ID:

Office Symbol/Organization:

SUBJECT: Civil Emergency Physician Medical Clearance

1. Mr./Ms. __________ of ___________ has been medically evaluated and:

a. is fit to deploy with a clearance code of:

b. is not fit to deploy.

This determination is based on a review of the completed medical screening questionnaire, follow-up with employee where determined necessary, and the anticipated work/environmental conditions described in the work-related and medical information sheet.

Comments to be entered by the USACE Medical Provider only.

2. Physician's Signature:

Signature of Physician Date Print Name Phone Number

Exhibit 2 – ENGLink Interactive

2016 version: 2.0610

Eunice Rose

ENGLink Interactive

Medical Screening Procedures (MEDICAL PROVIDER) Developed by:

General Dynamics -IT US Army Corps of Engineers Readiness Support Center

201 St. Michael Street Mobile, AL 36602

(877)-936-4546

Table of Contents:

Access the Dashboard

Reviewing an employee’s MSP

Physician’s Review and Clearance Code Assignment

MSP Incomplete—How to request more information from the employee

MSP Status Legend

Batch Printing Recently Submitted Medical Screening Packets

What Happens to the Medical Screening Packet

Access the Dashboard The Medical Provider will need to connect to ENGLink via a VPN connection to the Corps of Engineers network. Once connected, MEDICAL PROVIDER staff should go to https://englink2.usace.army.mil and login to begin using ENGLink.

1. Once logged into ENGLink, click the Tools tab

2. Click the Medical Screening Dashboard sub-link

3. The Medical Screening Dashboard will display

a. A listing of personnel with a status of In-Process (medical screening submitted to MEDICAL PROVIDER) is displayed, by default

b. MEDICAL PROVIDER personnel can search for employees by name, organization, UPASS user ID, or by status

Reviewing an employee’s MSP

1. Click the Actions button for an employee with a status of “In-

Process”

2. Select the Review option

3. The employee’s medical screening packet information will display on the screen.

4. Medical provider personnel will review the employee’s answers and note anything unusual. This page can be printed by using the browser’s print function

Physician’s Review and Clearance Code Assignment

1. Return to the Employee list and/or search

2. Click the Actions button for an employee with a status of “In- Process”

3. Select the Edit option

4. After reviewing the MSP, the physician will do the following on the Edit Medical Screening Packet page:

a. Assign a Clearance Code (CC)

b. Select a date the review was completed (by clicking the calendar icon)

c. Select an expiration date for the MSP

d. Choose the physician’s name for the Digital Signature

5. Once finished, the physician will click the Continue button

6. The status on the employee’s MSP will be updated and reflected at various locations within ENGLink

MSP Incomplete—How to request more information from the employee

1. Click the Actions button for an employee with a status of “In-

Process”

2. Select the Request More Info option

3. The Request More Information page will display. Enter what type of information is needed in the Comments box

Note:

Be careful of being too specific and potentially violating the employee’s privacy rights by exposing health related PII.

4. Once finished, click the Submit button

Note:

All changes to the employee’s MSP (status change or request for more information) will generate an email to the employee and his/her supervisor.

MSP Status Legend

Batch Printing Recently Submitted Medical Screening Packets

When new packets arrive, MEDICAL PROVIDER personnel can batch print all new submitted screenings. This increases the speed at which screenings can be reviewed. Do be aware that once the screenings are batch printed you should save the .pdf file that is generated due to the fact that the screenings are removed from the batch print que.

Here’s how to do a batch print

1. Login to ENGLink

2. Click the Tools tab

3. Click the Medical Screening Dashboard sub-link

4. Click the number listed next to the “Batch Print In-Process Packets” heading

5. A .pdf document will display. This document should be saved and printed

6. Once printed this document can be provided to the doctors for an expedient review of the recently submitted medical screenings.

What Happens to the Medical Screening Packet

1. When a medical screening packet (MSP) is submitted, it is immediately encrypted and sent to an email box at the medical provider.

2. A trained individual, at the Medical Provider, reviews the MSP and codes any abnormalities for the physician review. The physician then reviews the MSP and provides a code for the ENGLink database or requests for more information. This process rarely takes more than 5 working days, usually less than 2 working days (or quicker).

3. If the physician assigns a code, the technician enters a clearance memorandum into ENGLink with a physician’s signature. ENGLink will send an email letter to the individual and their supervisor listed in the personal data sheet. This code is also automatically recorded in the medical screening dashboard, the ENGLink personal data sheet, and, if applicable, the team readiness dashboard.

4. If the physician requests more information, the technician will submit a pending code in ENGLink and send an email request through ENGLink to the individuals requesting more information.

a. The physician will require more information if the MSP has an unexplained atypical response or conditions that warrant a note from the employee’s physician.

b. Due to HIPAA regulations, vagueness is required when requesting more information online. The employee will receive a standard note that requests them to call the contractor. The contractor responds to all calls/voicemails from the morning in the afternoon or in the morning for calls received in the afternoon the previous day.

c. Usually the employee will call back quickly. If this is the case, the contractor will discuss in depth what information is required from the employee’s physician in order to complete the review of the packet.

If the contractor requires a note from the employee’s physician, then the employee will receive an email with detailed description of what is required.

d. If the employee does not contact the contractor within two weeks, the contractor sends a second email to the USACE email address.

e. An employee has 60 days to call the contractor and provide any information required unless a valid reason for the delay is provided.

f. The contractor will try one last time to email the employee at 60 days. If the employee does not respond, the employee will declared non-deployable. The file is saved for a year so if the employee calls again the file will be available.

5. Any information provided in ENGLink, including the clearance memorandum, which provides the deployment code, does not include the employee’s protected medical information.

6. If an employee would like to know why they have been assigned the code of non-deployable, they should contact the Medical Provider by phone or email. ENGLink is not provided with information to explain why the non-deployable status (or any other status) has been assigned. It is important to set a time and number for the physician to return the call.

Contact ENGLink

If you have questions or need assistance, please contact the ENGLink Help Desk at 1-877-936-4546 or email us at englink@usace.army.mil

ENGLink Help Desk:

Ronald Gaston....................................Ronald.C.Gaston@usace.army.mil James Walsh.......................................James.A.Walsh@usace.army.mil

ENGLink Training Manager:

Rodney Moody...................................Rodney.S.Moody@usace.army.mil

ENGLink Project Managers:

Brandon Taylor ..................................Brandon.L.Taylor@usace.army.mil GDIT Richard Sien ............................Richard.Sien@gdit.com