05. W912LP26Q4005_ATTCH_5_PWS Technical Exhibit 3.pdf

This is a template document for the Iowa Army National Guard Occupational Health Report used to conduct medical examinations for employment purposes. The document consists of three primary components: a Medical Examination cover form, a Physical Examination form, and a Medical History Questionnaire.

The Medical Examination form captures basic examinee information and allows the examiner to document the exam type (Medical Surveillance, Respirator Evaluation, Post-Offer Pre-Placement, Transfer, Termination/Retirement, or Special Exam) and medical qualification status. Examiners indicate whether the examinee is medically qualified for essential job functions, not qualified, qualified with limitations/accommodations, or has a temporary condition requiring resolution. The form includes sections for respirator qualification documentation with specific types (All, Negative Pressure, SCBA, PAPR), follow-up exam scheduling, and examiner certification options. The Physical Examination form documents vital signs (height, weight, blood pressure, pulse), vision testing (corrected and uncorrected measurements for far, near, and peripheral vision including phoria testing), and physical exam findings for multiple body systems including skin, head/neck, chest, lungs, heart, abdomen, spine, extremities, and hand assessments, with designated areas for abnormal findings and provider comments. The Medical History Questionnaire is comprehensive, covering general medical history (asthma, diabetes, cancer, etc.), hospitalization and surgical history, system-based reviews addressing ear/nose/throat, heart, shoulder, eyes, respiratory, skin, neck, hand/wrist/elbow, back, pain, knee, digestive system, genitourinary/reproductive, and neurologic/psychiatric conditions. Additional sections address occupational history, work-related injuries, workers compensation, work restrictions, disability benefits, current medical care, accommodations needed, personal protective equipment usage, hazardous material exposure history (asbestos, dust, lead, solvents, etc.), leisure activities, allergies, medications, immunizations, and diagnostic testing history. The examinee must sign an attestation that the information provided is true and correct.