04. W912LP26Q4003_ATTCH_4_PWS Technical Exhibit 3.pdf

This document is an Occupational Health Report template used by the Iowa Army National Guard Occupational Health program to document medical examinations for employment purposes.

The template consists of four interconnected forms: a Medical Examination form, a Physical Examination form, and a comprehensive Medical History Questionnaire. The Medical Examination form captures the examination type (periodic surveillance, respirator evaluation, post-offer, transfer, termination, or special exam), examinee information, work site, and job title, followed by the examiner's determination of medical qualification for essential job functions. Options include full qualification, disqualification, qualification with limitations/accommodations, temporary disqualification pending condition resolution, and deferred recommendation pending additional information. The form includes specific sections for respirator qualification assessment with restrictions noted. The Physical Examination form documents vital signs (height, weight, blood pressure, pulse), vision testing (far and near, corrected and uncorrected), phoria measurements, and other procedures including chest X-rays, EKG, blood tests, and spirometry. A detailed physical exam checklist addresses skin, head/neck, chest, lungs, heart, abdomen, spine, extremities, and hand strength assessments. The Medical History Questionnaire is comprehensive, addressing general medical history (asthma, diabetes, heart conditions, cancer, etc.), system reviews (ear/nose/throat, respiratory, cardiac, gastrointestinal, neurological, dermatological, orthopedic), occupational history, work restrictions, disability status, required accommodations, personal protective equipment usage, and exposure history to hazardous materials including asbestos, lead, solvents, pesticides, and radioactive materials. Additional sections cover leisure activities, allergies, current medications, immunization records, and prior diagnostic testing. Examiners provide explanations of abnormal findings and any items marked affirmatively on the medical history questionnaire.