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03/19/2014 Agreement AMY HEAVILIN, CPA CLERK OF CIRCUIT COURT & COMPTROLLER p�i'i-ol i MONROE COUNTY,FLORIDA mil', DATE: April 16, 2014 TO: Teresa Aguiar, Director of Employee Services ATTN: Christine Diaz FROM: Vitia Fernandez, D.C. M..rol, t 1, At the 204, 2013, Board of County Commissioner's meeting the Board granted approval and execution of Item C23 Board granted approval of Contract with New Truman Medical to provide employment physical services. Attached is a duplicate original of the above-mentioned for your handling. Should you have any questions please do not hesitate to contact this office. cc: County Attorney (electronic copy) Finance (electronic copy) File 500 Whitehead Street Suite 101,PO Box 1980,Key West,FL 33040 Phone:305-295-3130 Fax:305-295-3663 3117 Overseas Highway,Marathon,FL 33050 Phone:305-289-6027 Fax:305-289-6025 88820 Overseas Highway,Plantation Key,FL 33070 Phone:852-7145 Fax:305-852-7146 AGREEMENT EMPLOYMENT PHYSICAL SERVICES TABLE OF CONTENTS SECTION ONE - Scope of Services SECTION TWO - County Forms and Insurance Forms ATTACHMENTS: A. Post-offer and Fit for Duty Physical Forms (4 pages) B. DOT Physical (9 pages) C. Respirator Physical "Part I" (4 pages) Respirator Physical "Part II" (5 pages) Respirator Policy "III" (12 pages) D. NFPA Guidelines 2000 Edition — Firefighter Physical (49 pages) 1 MONROE COUNTY CONTRACT FOR EMPLOYMENT PHYSICAL SERVICES THIS AGREEMENT ("Agreement") is made and entered into this 19th day of March. 2014, by MONROE COUNTY("COUNTY"), a political subdivision of the State of Florida, whose address is 1100 Simonton Street, Key West, Florida 33040 and New Truman Medical Center, P.A. ("CONTRACTOR"), whose address is at 540 Truman Avenue, Key West, FL 33040. Section 1. SCOPE OF SERVICES CONTRACTOR shall do, perform and carry out in a professional and proper manner certain duties as described in the Scope of Services— Section One—which is attached hereto and made a part of this agreement. CONTRACTOR shall provide the scope of services in Section One for COUNTY. CONTRACTOR warrants that it is authorized by law to engage in the performance of the activities herein described, subject to the terms and conditions set forth in these Agreement documents. The CONTRACTOR shall at all times exercise independent, professional judgment and shall assume professional responsibility for the services to be provided. Contractor shall provide services using the following standards, as a minimum requirement: A. The CONTRACTOR shall maintain adequate staffing levels to provide the services required under the Agreement. B. The contractor is responsible for obtaining proper releases from the employee or prospective employee in order to discuss the results with Monroe County BOCC. C. The contractor will provide the required services at the location of: 540 Truman Avenue Key West, FL 33040 Phone: 305-296-4399 Fax: 305-294-8270 D. All urine screens will conform with the standard chain of custody protocols mandated by state and federal regulations. E. The Contractor will have an employee designated as coordinator or facilitator to assist in the communications with the Monroe County BOCC's primary contact personnel. F. Appointments will be available throughout the business hours of the facility: Monday— Sunday 9:00 a.m. — 5:00 p.m. Walk-ins will also be accepted if an appointment cannot be reasonably scheduled. G. The facility will be available 24 hours a day, 7 days a week for post accident, random and reasonable suspicion alcohol and drug screening. • The Human Resources office will contact Amber McGill or Deena Richardson via private phone line to request that the physician administer the test. • The authorized Human Resources representative or the authorized supervisor shall complete the appropriate forms either the same business day (or by the next business day if the test is after normal working hours) in order for the physician to perform the required test. 2 • The employee will be tested at the physician's facility located at 1446 Kennedy Drive, Key West. H. Appointments will be seen by the contractor in a reasonable and timely fashion. The Contractor will provide the County with at least a 24— 48 hour turnaround time for the receipt of any drug and/or physical results. J. The Medical Review Officer will be available for contact by the Monroe County BOCC or its employees to answer questions about the effect of prescribed drugs. Part of the requirements set forth by the State of Florida drug free workplace policy, which Monroe County has adopted, and the Department of Transportation, the County must have a qualified Medical Review Officer"MRO" perform drug screening services. The MRO receives lab reports from the laboratory(as governed by regulations); Reviews lab reports for integrity, authenticity, false negatives, and false positives; interprets lab results, including verification of lab positives; reports lab reports to the employer(as defined by rules and regulations). K. The personnel shall not be employees of or have any contractual relationship with the County. To the extent that Contractor uses subcontractors or independent contractors, this Agreement specifically requires that subcontractors and independent contractors shall not be an employee of or have any contractual relationship with County. L. All personnel engaged in performing services under this Agreement shall be fully qualified, and, if required, to be authorized or permitted under State and local law to perform such services. Section 2. QUALIFICATIONS NECESSARY OF CONTRACTOR The CONTRACTOR must certify at least annually that all staff members, independent contractors, subcontracted work, if any, all service providers it uses, engages or manages, comply with Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules. Physical examinations will be conducted by, or under the direct supervision, of a physician or medical doctor currently licensed and practicing general medicine in the State of Florida. The examining physician may employ assistants properly licensed and trained, as necessary, to perform laboratory tests and/or assist in all phases of the examination. Section 3. COUNTY'S RESPONSIBILITIES 3.1 Provide all best available information as to the COUNTY'S requirements for the Scope of Services described in Section One to this Agreement. 3.2 Designate in writing a person with authority to act on the COUNTY'S behalf on all matters concerning said services. Section 4. TERM OF AGREEMENT 4.1 The term of this contract will be for one (1) year beginning March 19, 2014 and shall automatically renew for successive one year terms unless and until either party gives the other notice of cancellations in accordance with the terms set forth in Section 7. 3 Section 5. COMPENSATION Compensation to CONTRACTOR is outlined in the Scope of Services —Section One. Section 6. PAYMENT TO CONTRACTOR 6.1 Payment will be made according to the Florida Local Government Prompt Payment Act. Any request for payment must be in a form satisfactory to the Clerk of Courts for Monroe County (Clerk). The request must describe in detail the services performed and the payment amount requested. The CONTRACTOR must submit invoices to the appropriate offices marked Human Resources. The respective office supervisor and the Administrator of Human Resources, who will review the request, note his/her approval on the request and forward it to the Clerk for payment. 6.2 Continuation of this Agreement is contingent upon annual appropriation by Monroe County Board of County Commissioners. Section 7. CONTRACT TERMINATION Either party may terminate this Agreement because of the failure of the other party to perform its obligations under the Agreement. Either party may terminate this Agreement without cause upon sixty (60) days' notice to the other party in accordance with Section 9 of this Agreement. The County shall pay CONTRACTOR for all work performed through the date of termination. Section 8. CONTRACTOR'S ACCEPTANCE OF CONDITIONS A. CONTRACTOR hereby agrees that he has carefully examined the RFP, his response, and this Agreement and has made a determination that he/she has the personnel, equipment, and other requirements suitable to perform this work and assumes full responsibility therefore. The provisions of the Agreement shall control any inconsistent provisions contained in the specifications. All specifications have been read and carefully considered by CONTRACTOR, who understands the same and agrees to their sufficiency for the work to be done. Under no circumstances, conditions, or situations shall this Agreement be more strongly construed against COUNTY than against CONTRACTOR. B. Any ambiguity or uncertainty in the specifications shall be interpreted and construed by COUNTY, and its decision shall be final and binding upon all parties. C. The passing, approval, and/or acceptance by COUNTY of any of the services furnished by CONTRACTOR shall not operate as a waiver by COUNTY of strict compliance with the terms of this Agreement, and specifications covering the services. D. CONTRACTOR agrees that County Administrator or his designated representatives may visit CONTRACTOR'S facility (ies) periodically to conduct random evaluations of -- -- -services during CONTRACTOR'S normal business hours. E. CONTRACTOR has, and shall maintain throughout the term of this Agreement, appropriate licenses and approvals required to conduct its business, and that it will at all times conduct its business activities in a reputable manner. Proof of such licenses and approvals shall be submitted to COUNTY upon request. F. Pursuant to Florida Statute §119.0701, Contractor and its subcontractors shall comply with all public records laws of the State of Florida, specifically to: i. Keep and maintain public records that ordinarily and necessarily would be required by Monroe County in the performance of this Agreement. 4 ii. Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes, Chapter 119 or as otherwise provided by law. iii. Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law. iv. Meet all requirements for retaining public records and transfer, at no cost, to Monroe County all public records in possession of the contractor upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. All records stored electronically must be provided to Monroe County in a format that is compatible with the information technology systems of Monroe County. Section 9. NOTICES Any notice required or permitted under this agreement shall be in writing and hand delivered or mailed, postage prepaid, to the other party by certified mail, returned receipt requested, to the following: To the COUNTY: Human Resources Administrator 1100 Simonton Street, Suite 2-268 Key West, Florida 33040 To the CONTRACTOR: New Truman Medical 540 Truman Avenue Key West, FL 33040 Section 10. RECORDS CONTRACTOR shall maintain all books, records, and documents directly pertinent to performance under this Agreement in accordance with generally accepted accounting principles consistently applied. Each party to this Agreement or their authorized representatives shall have reasonable and timely access to such records of each other party to this Agreement for public records purposes during the term of the agreement and for four years following the termination of this Agreement. If an auditor employed by the COUNTY or Clerk determines that monies paid to CONTRACTOR pursuant to this Agreement were spent for purposes not authorized by this Agreement, the CONTRACTOR shall repay the monies together with interest calculated pursuant to Section 55.03 of the Florida Statutes, running from the date the monies were paid to CONTRACTOR. Section 11. EMPLOYEES SUBJECT TO COUNTY ORDINANCE NOS. 010 AND 020-1990 The CONTRACTOR warrants that it has not employed, retained or otherwise had act on its behalf any former County officer or employee subject to the prohibition of Section 2 of 5 Ordinance No. 010-1990 or any County officer or employee in violation of Section 3 of Ordinance No. 020-1990. For breach or violation of this provision the COUNTY may, in its discretion, terminate this agreement without liability and may also, in its discretion, deduct from the agreement or purchase price, or otherwise recover the full amount of any fee, commission, percentage, gift, or consideration paid to the former County officer or employee. Section 12. CONVICTED VENDOR A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on an Agreement with a public entity for the construction or repair of a public building or public work, may not perform work as a CONTRACTOR, supplier, subcontractor, or CONTRACTOR under Agreement with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017 of the Florida Statutes, for the Category Two for a period of 36 months from the date of being placed on the convicted vendor list. Section 13. GOVERNING LAW, VENUE, INTERPRETATION, COSTS AND FEES This Agreement shall be governed by and construed in accordance with the laws of the State of Florida applicable to Agreements made and to be performed entirely in the State. In the event that any cause of action or administrative proceeding is instituted for the enforcement or interpretation of this Agreement, the COUNTY and CONTRACTOR agree that venue shall lie in the appropriate court or before the appropriate administrative body in Monroe County, Florida. Section 14. SEVERABILITY If any term, covenant, condition or provision of this Agreement(or the application thereof to any circumstance or person) shall be declared invalid or unenforceable to any extent by a court of competent jurisdiction, the remaining terms, covenants, conditions and provisions of this Agreement, shall not be affected thereby; and each remaining term, covenant, condition and provision of this Agreement shall be valid and shall be enforceable to the fullest extent permitted by law unless the enforcement of the remaining terms, covenants, conditions and provisions of this Agreement would prevent the accomplishment of the original intent of this Agreement. The COUNTY and CONTRACTOR agree to reform the Agreement to replace any stricken provision with a valid provision that comes as close as possible to the intent of the stricken provision. Section 15. ATTORNEY'S FEES AND COSTS The COUNTY and CONTRACTOR agree that in the event any cause of action or administrative proceeding is initiated or defended by any party relative to the enforcement or interpretation of this Agreement, the prevailing party shall be entitled to reasonable attomey's fees, and court costs, as an award against the non-prevailing party. Mediation proceedings initiated and conducted pursuant to this Agreement shall be in accordance with the Florida Rules of Civil Procedure and usual and customary procedures required by the Circuit Court of Monroe County. Section 16. BINDING EFFECT 6 The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to the benefit of the COUNTY and CONTRACTOR and their respective legal representatives, successors, and assigns. Section 17. AUTHORITY Each party represents and warrants to the other that the execution, delivery and performance of this Agreement have been duly authorized by all necessary County and corporate action, as required by law. Section 18. ADJUDICATION OF DISPUTES OR DISAGREEMENTS COUNTY and CONTRACTOR agree that all disputes and disagreements shall be attempted to be resolved by meet and confer sessions between representatives of each of the parties. If the issue or issues are still not resolved to the satisfaction of the parties, then any party shall have the right to seek such relief or remedy as may be provided by this Agreement or by Florida law. This Agreement shall not be subject to arbitration. Section 19. COOPERATION In the event any administrative or legal proceeding is instituted against either party relating to the formation, execution, performance, or breach of this Agreement, COUNTY and CONTRACTOR agree to participate, to the extent required by the other party, in all proceedings, hearings, processes, meetings, and other activities related to the substance of this Agreement or provision of the services under this Agreement. COUNTY and CONTRACTOR specifically agree that no party to this Agreement shall be required to enter into any arbitration proceedings related to this Agreement. Section 20. NONDISCRIMINATION COUNTY and CONTRACTOR agree that there will be no discrimination against any person, and it is expressly understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this Agreement automatically terminates without any further action on the part of any party, effective the date of the court order. The parties agree to comply with all Federal and Florida statutes, and all local ordinances, as applicable, relating to nondiscrimination. These include but are not limited to: 1) Title VII of the Civil Rights Act of 1964 (PL 88-352) which prohibits discrimination in employment on the basis of race, color, national origin; 2)Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681- 1683, and 1685-1686), which prohibits discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discrimination on the basis of handicaps: 4) The Age Discrimination Act of 1975, as amended (42 USC ss. 6101- 6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972 (PL 29-255), as amended, relating to nondiscrimination on the basis of drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912, ss. 523 and 527 (42 USC ss. 690dd-3 and 290ee-3) as amended, relating to confidentiality of alcohol and drug abuse patient records; 8) Title VIII of the Civil Rights Act of 1968 (42 USC ss. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The Americans with Disabilities Act of 1990 (42 USC s. 1201), as may be amended from time to time, relating to nondiscrimination on the basis of disability; 10) Monroe County Code Chapter 7 13, Article VI, which prohibits discrimination on the basis of race, color, sex, religion, national origin, ancestry, sexual orientation, gender identity or expression, familial status or age; and 11) any other nondiscrimination provisions in any Federal or state statutes which may apply to the parties to, or the subject matter of, this Agreement. Section 21. COVENANT OF NO INTEREST COUNTY and CONTRACTOR covenant that neither presently has any interest, and shall not acquire any interest, which would conflict in any manner or degree with its performance under this Agreement, and that only interest of each is to perform and receive benefits as recited in this Agreement. Section 22. CODE OF ETHICS COUNTY agrees that officers and employees of the COUNTY recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or use of certain information. Section 23. NO SOLICITATION/PAYMENT The COUNTY and CONTRACTOR warrant that, in respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. Section 24. PUBLIC ACCESS The COUNTY and CONTRACTOR shall allow and permit reasonable access to, and inspection of, all documents, papers, letters or other materials in its possession or under its control subject to the provisions of Chapter 119, Florida Statutes, and made or received by the COUNTY and CONTRACTOR in conjunction with this Agreement; and the COUNTY shall have the right to unilaterally cancel this Agreement upon violation of this provision by CONTRACTOR. Section 25. NON-WAIVER OF IMMUNITY Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the COUNTY and the CONTRACTOR in this Agreement and the acquisition of any commercial liability insurance coverage, self-insurance coverage, or local government liability insurance pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage, nor shall any Agreement entered into by the COUNTY be required to contain any provision for waiver. Section 26. PRIVILEGES AND IMMUNITIES All of the privileges and immunities from liability, exemptions from laws, ordinances, and rules 8 and pensions and relief, disability, workers' compensation, and other benefits which apply to the activity of officers, agents, or employees of any public agents or employees of the COUNTY, when performing their respective functions under this Agreement within the territorial limits of the COUNTY shall apply to the same degree and extent to the performance of such functions and duties of such officers, agents, volunteers, or employees outside the territorial limits of the COUNTY. Section 27. LEGAL OBLIGATIONS AND RESPONSIBILITIES Non-Delegation of Constitutional or Statutory Duties. This Agreement is not intended to, nor shall it be construed as, relieving any participating entity from any obligation or responsibility imposed upon the entity by law except to the extent of actual and timely performance thereof by any participating entity, in which case the performance may be offered in satisfaction of the obligation or responsibility. Further, this Agreement is not intended to, nor shall it be construed as, authorizing the delegation of the constitutional or statutory duties of the COUNTY, except to the extent permitted by the Florida constitution, state statute, and case law. Section 28. NON-RELIANCE BY NON-PARTIES No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to enforce or attempt to enforce any third-party claim or entitlement to or benefit of any service or program contemplated hereunder, and the COUNTY and the CONTRACTOR agree that neither the COUNTY nor the CONTRACTOR or any agent, officer, or employee of either shall have the authority to inform, counsel, or otherwise indicate that any particular individual or group of individuals, entity or entities, have entitlements or benefits under this Agreement separate and apart, inferior to, or superior to the community in general or for the purposes contemplated in this Agreement. Section 29. ATTESTATIONS CONTRACTOR agrees to execute such documents as the COUNTY may reasonably require, including, but not being limited to, a Public Entity Crime Statement, an Ethics Statement, and a Drug-Free Workplace Statement, Lobbying and Conflict of Interest Clause, and Non-Collusion Agreement. Section 30. NO PERSONAL LIABILITY No covenant or agreement contained herein shall be deemed to be a covenant or agreement of any member, officer, agent or employee of Monroe County in his or her individual capacity, and no member, officer, agent or employee of Monroe County shall be liable personally on this Agreement or be subject to any personal liability or accountability by reason of the execution of this Agreement. Section 31. EXECUTION IN COUNTERPARTS This Agreement may be executed in any number of counterparts, each of which shall be regarded as an original, all of which taken together shall constitute one and the same instrument and any of the parties hereto may execute this Agreement by signing any such counterpart. Section 32. SECTION HEADINGS Section headings have been inserted in this Agreement as a matter of convenience of reference only, and it is agreed that such section headings are not a part of this Agreement and will not be 9 used in the interpretation of any provision of this Agreement. Section 33. INSURANCE POLICIES 33.1 General Insurance Requirements for Other Contractors and Subcontractors. As a pre-requisite of the work governed, the CONTRACTOR shall obtain, at his/her own expense, insurance as specified in any attached schedules, which are made part of this contract. The CONTRACTOR will ensure that the insurance obtained will extend protection to all Subcontractors engaged by the CONTRACTOR. As an alternative, the CONTRACTOR may require all Subcontractors to obtain insurance consistent with the attached schedules; however CONTRACTOR is solely responsible to ensure that said insurance is obtained and shall submit proof of insurance to COUNTY. Failure to provide proof of insurance shall be grounds for termination of this Agreement. The CONTRACTOR will not be permitted to commence work governed by this contract until satisfactory evidence of the required insurance has been furnished to the COUNTY as specified below. Delays in the commencement of work, resulting from the failure of the CONTRACTOR to provide satisfactory evidence of the required insurance, shall not extend deadlines specified in this contract and any penalties and failure to perform assessments shall be imposed as if the work commenced on the specified date and time, except for the CONTRACTOR's failure to provide satisfactory evidence. The CONTRACTOR shall maintain the required insurance throughout the entire term of this contract and any extensions specified in the attached schedules. Failure to comply with this provision may result in the immediate suspension of all work until the required insurance has been reinstated or replaced and/or termination of this Agreement and for damages to the COUNTY. Delays in the completion of work resulting from the failure of the CONTRACTOR to maintain the required insurance shall not extend deadlines specified in this contract and any penalties and failure to perform assessments shall be imposed as if the work had not been suspended, except for the CONTRACTOR's failure to maintain the required insurance. The CONTRACTOR shall provide, to the COUNTY, as satisfactory evidence of the required insurance, either: • Certificate of Insurance or • A Certified copy of the actual insurance policy. The County, at its sole option, has the right to request a certified copy of any or all insurance policies required by this contract. All insurance policies must specify that they are not subject to cancellation, non-renewal, material change, or reduction in coverage unless a minimum of thirty (30)days prior notification is given to the County by the insurer. The acceptance and/or approval of the Contractor's insurance shall not be construed as relieving the Contractor from any liability or obligation assumed under this contract or imposed by law. The Monroe County Board of County Commissioners, its employees and officials will be included as "Additional Insured"on general liability policies. 33.2 General Liability Insurance Requirements For Contract Between County And Contractor 10 Prior to the commencement of work governed by this contract, the CONTRACTOR shall obtain General Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum: • Premises Operations • Bodily Injury Liability • Expanded Definition of Property Damage The minimum limits acceptable shall be: $300,000 Combined Single Limit(CSL) If split limits are provided, the minimum limits acceptable shall be: $200,000 per Person $300,000 per Occurrence $ 50,000 Property Damage An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its provisions should include coverage for claims filed on or after the effective date of this contract. In addition, the period for which claims may be reported should extend for a minimum of twelve (12) months following the acceptance of work by the County. The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. 33.3 Workers' Compensation Insurance Requirements Prior to commencement of work governed by this contract, the CONTRACTOR shall obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition, the CONTRACTOR shall obtain Employers' Liability Insurance with limits of not less than: $100,000 Bodily Injury by Accident $500,000 Bodily Injury by Disease, policy limits $100,000 Bodily Injury by Disease, each employee Coverage shall be maintained throughout the entire term of the contract. Coverage shall be provided by a company or companies authorized to transact business in the state of Florida. 33.4 Professional Liability Requirements Recognizing that the work governed by this contract involves the furnishing of advice or services of a professional nature, the Contractor shall purchase and maintain, throughout the life of the contract, Professional Liability Insurance which will respond to damages resulting from any claim arising out of the performance of professional services or any error or omission of the Contractor arising out of work governed by this contract. 11 The minimum limits of liability shall be: $250,000 per occurrence and $750,000 aggregate Section 34. INDEMNIFICATION The CONTRACTOR does hereby consent and agree to indemnify and hold harmless the COUNTY, its Mayor, the Board of County Commissioners, appointed Boards and Commissions, Officers, and the Employees, and any other agents, individually and collectively, from all fines, suits, claims, demands, actions, costs, obligations, attorney's fees, or liability of any kind arising out of the sole negligent actions of the CONTRACTOR or substantial and unnecessary delay caused by the willful nonperformance of the CONTRACTOR and shall be solely responsible and answerable for any and all accidents or injuries to persons or property arising out of its performance of this contract. The amount and type of insurance coverage requirements set forth hereunder shall in no way be construed as limiting the scope of indemnity set forth in this paragraph. Further the CONTRACTOR agrees to defend and pay all legal costs attendant to acts attributable to the sole negligent act of the CONTRACTOR. At all times and for all purposes hereunder, the CONTRACTOR is an independent contractor and not an employee of the Board of County Commissioners. No statement contained in this agreement shall be construed so as to find the CONTRACTOR or any of his/her employees, contractors, servants or agents to be employees of the Board of County Commissioners for Monroe County. As an independent contractor the CONTRACTOR shall provide independent, professional judgment and comply with all federal, state, and local statutes, ordinances, rules and regulations applicable to the services to be provided. The CONTRACTOR shall be responsible for the completeness and accuracy of its work, plan, supporting data, and other documents prepared or compiled under its obligation for this project, and shall correct at its expense all significant errors or omissions therein which may be disclosed. The cost of the work necessary to correct those errors attributable to the CONTRACTOR and any damage incurred by the COUNTY as a result of additional costs caused by such errors shall be chargeable to the CONTRACTOR. This provision shall not apply to any maps, official records, contracts, or other data that may be provided by the COUNTY or other public or semi-public agencies. The CONTRACTOR agrees that no charges or claims for damages shall be made by it for any delays or hindrances attributable to the COUNTY during the progress of any portion of the services specified in this contract. Such delays or hindrances, if any, shall be compensated for by the COUNTY by an extension of time for a reasonable period for the CONTRACTOR to complete the work schedule. Such an agreement shall be made between the parties. 12 IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed on the &IPTr day of April 20Pi. ' j�� Qjjjt?Li MONROE COUNTY BOARD OF COUNTY COMMISSIONERS RK by "scA Y Deputy Clerk , or/Chairm (CORPORATE SEAL) ATTEST: NEW TRUMA ICAL CENTER, P.A. Print name by �q.. Title: r.'�<,P aft-aer T cc N c o -, V p LL cc c L.): MONROE COUNTY ATTORNEY ce ZA APP VE AS.TO,F M' p s.o— o0 � h •L 56... CY THIA L. HALL W o ASSISTAN COUNTY ATTORNEY v za Date a —IY- 2-DI L 13 SECTION ONE SCOPE OF SERVICES EMPLOYMENT PHYSICAL SERVICES The scope of services to be provided on an as needed basis by the Provider may include, but not be limited to, the following. The forms to be reviewed and completed by the Contractor are attached to this agreement (Attachments A - E). All results will include: • Written interpretation of test results in common terms and written explanation of the significance of each abnormality or written explanation of those results which are outside the normal range. • Examining physician's written recommendation concerning future action on any condition considered outside the normal range. • Written recommendation of specific reasonable accommodations in accordance with the ADA. SERVICE FEE DRUG SCREEN: When requested, a drug screen will (Collection, Lab, MRO be performed by the physician and review) 10 panel State will be either scheduled or done on a $60.00 Requirement walk-in basis. After hours drug testing for post $25.00 accident, random, and reasonable per test suspicion drug screening. DRUG SCREEN: When requested, a drug screen will (Collection, Lab, MRO be performed by the physician and review) 5 panel will be either scheduled or done on a $40.00 Department of walk-in basis. Transportation Requirement After hours drug testing for a $25.00 moving violation or an accident per test where a fatality occurs. Medical Review Officer The MRO receives lab reports from Included (MRO) REVIEW the laboratory(as governed by regulations); Reviews lab reports for integrity, authenticity, false negatives, and false positives; interprets lab results, including verification of lab positives; reports lab reports to the employer(as defined by rules and regulations). BLOOD ALCOHOL When requested, Blood Alcohol (Collection, Lab, MRO Screens will be performed by the review) physician and will be either $30.00 14 scheduled or done on a walk-in basis. After hours testing for post accident, $25.00 per random and reasonable suspicion test alcohol screen. BREATH ALCOHOL When requested, may be used for screening. If breath alcohol screen is $30.00 positive, a blood screen will be performed. After hours testing for post accident, $25.00 per random, and reasonable suspicion test alcohol screening. If breath alcohol screen is positive, a blood screen will be performed at the rate designated above. PPD-TB screen When requested, a PPD-TB screen will be scheduled and performed by the $25.00 physician during the facility's normal business hours. HEPATITIS A When requested, a Hepatitis A $110.00 each inoculation will be scheduled and (Series of 2 performed by the physician during the total) facility's normal business hours. HEPATITIS B When requested, a Hepatitis B inoculation(s) will be scheduled and $110.00 each performed by the physician during the (Series of 3 facility's normal business hours. total) TYPHOID When requested, a Typhoid inoculation will be scheduled and performed by the N/A physician during the facility's normal business hours. TETANUS When requested, a Tetanus inoculation Combined will be scheduled and performed by the with physician during the facility's normal Diphtheria business hours. below: DIPHTHERIA When requested, a Diphtheria inoculation will be scheduled and $55 performed by the physician during the facilit 's normal business hours. DOT PHYSICAL: When requested, a DOT physical will (SEE ATTACHMENT be scheduled and performed by the $65.00 "B"to be completed by physician during the facility's normal employee and physician) business hours. Includes exam and physician review of employee health history and job description. The DOT physical is initially performed in conjunction with a post-offer 15 physical. Thereafter, only a DOT physical is performed by the physician. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. POST-OFFER When requested, a post-offer physical PHYSICAL: will be scheduled and performed by the (SEE ATTACHMENT physician during the facility's normal $65.00 "A" to be completed by business hours. Includes exam and employee and physician) physician review of employee health history and job description. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. FITNESS FOR DUTY When requested, a Fitness for Duty PHYSICAL (SEE Physical may be requested at any time ATTACHMENT"A"to be by the employer in the employee's $65.00 completed by employee respective area of work. The exam will and physician) be scheduled during the facility's normal business hours. Includes physician review of employee health history, exam, review of job duties and medical records if necessary. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. RESPIRATOR When requested, a Respirator physical PHYSICAL(SEE will be scheduled and performed by the ATTACHMENTS "C" physician during the facility's normal $85.00 PART I & II to be business hours. Includes exam and completed by employee physician review of employee health and physician) history and job description. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. Also required: Chest X-ray and S.riromet . CHEST X RAY Chest X Ray is normally done in conjunction with the Respirator $45.00 physical if there is an issue with the spirometry results. SPIROMETRY Normally done in conjunction with the Respirator physical. All employees who use a respirator will have a $45.00 Spirometry when hired. Normally done in conjunction with the HEARING/AUDIOGRAM appropriate physical. May be requested $30.00 separately by Monroe County BOCC. 16 CHEMICAL Tests Glucose(sugar), kidneys, liver(1 $25.00 PANEL/CMP tube of blood drawn). CBC Test to see if Anemic; if any infections $25.00 within the body; if dehydrated(test from 1 of the tubes of blood drawn). LIPIDS Tests good cholesterol and bad $35.00 (CHOLESTEROL) cholesterol ( one of the tubes of blood drawn) UA DIP Normally done in conjunction with the $10.00 DOT physical. UA WITH MICRO $35.00 The Contractor shall retain all records pertaining to this contract for a period of four (4) years after the termination of this contract. • The County, the Clerk, the State Auditor General, and agents thereof shall have access to Contractor's books, records, and documents required by this contract for the purposes of inspection or audit during normal business hours, at the Contractor's place(s) of business. 17 SECTION TWO: COUNTY FORMS AND INSURANCE FORMS LOBBYING AND CONFLICT OF INTEREST CLAUSE SWORN STATEMENT UNDER ORDINANCE NO. 010-1990 MONROE COUNTY, FLORIDA ETHICS CLAUSE "NEW TRUMAN MEDICAL" (Company) "...warrants that he/it has not employed, retained or otherwise had act on his/her behalf any former County officer or employee in violation of Section 2 of Ordinance No. 010-1990 or any County officer or employee in violation of Section 3 of Ordinance No. 010-1990. For breach or violation of this provision the County may, in its discretion, terminate this Agreement without liability and may also, in its discretion, deduct from the Agreement or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former County officer or employee." (Signatu�... Date: 3! c7 // STATE OF: Florio¢ COUNTY OF: Mon rse Subscribed and sworn to (or affirmed) before me on ,H.rr_k 4 / R9IH (date) by I Mud<V Al gay (name of affiant). He/She is personally known to me or has produced t7riJett ucc+"r (type of identification)as identification. NOTARY PUBLIC My Commission Expires: 'W.A93 •yF' Notary Pudic State d Flats Garret Cabrera My Oemmia h/2 E5199185 18 n Eapirn C9/it/]015 �� yy NON-COLLUSION AFFIDAVIT /�.'yNrNty1/ack;y .j of the city of Ik tifQ Jf� L according to law on my oath, and under penalty of perjury, depose and say that 1. lam T.��,4y //[a C kQ y of the firm of the bidder making the Proposal for the project described in the Request for Proposals for Pay/i iVS ralir a r. / trey, c a s ' and that I executed the said proposal with full authority to do so; 2. The prices in this bid have been arrived at independently without collusion, consultation, communication or agreement for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor; 3. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to bid opening, directly or indirectly, to any other bidder or to any competitor; and 4. No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit, or not to submit, a bid for the purpose of restricting competition; and 5. The statements contained in this affidavit are true and correct, and made with full knowledge that Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. (Signature)�j Date: /' (/ STATE OF: Florida COUNTY OF: Mo^rvc Subscribed and sworn to (or affirmed) before me on rittarch 22)V (date) by T;s47f6y M'Aw (name of affiant). He/She is personally known to me or has produced 9c fit rn C icrnsc (type of identification) as identification. SS - ai,cs;a„mnow NOTARY PUBLIC et Cabrera FF1on EE 129169 ,plea.09n„aos My Commission Expires: ‘J//��2-°/5 19 Notary Public State elnova set: Garret Ga Cabrera My CanmMbn EEtISIMF l0,ike Expos 0er11Y201E DRUG-FREE WORKPLACE FORM The undersigned vendor in accordance with Florida Statutes Section 287.087 hereby certifies that: NEW TRUMAN MEDICAL (Name of Business) 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Informs employees about the dangers of drug abuse in the workplace, the business' policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Gives each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1). 4. In the statement specified in subsection (1), notifies the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nob contendere to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5)days after such conviction. 5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, or any employee who is so convicted. 6. Makes a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. (Signatu Date: '�/4/` ! V STATE OF: Ftor,da COUNTY OF: M onra Subscribed and sworn to (or affirmed) before me on A..cS y , 30ry (date) by key (name of affiant). He/She is personally known to me or has produced Orivrs L4-.r-r (type of identification) as identification. NOTARY PUBLIC My Commission Ex•ires' 9 // .' r- _ „a' i. Notary MAIN Sm.at Ronda I Gent Cabrera y d My Cemmb•wn EE12e18S 20 9-w„d :zoo OBtl1M2D15 PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list." I have read the above and state that neither NEW TRUMAN MEDICAL (Contractor's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. (Signatu / Date: , ( l(/ STATE OF: F)aricj, COUNTY OF: M>nrof Subscribed and sworn to (or affirmed) before me on M 1, u / Ply (date) by T,m y M.c.r r (name of affiant). He/She is personally known to me or has produced // firmer-- Ln:a (type of identification)as identification. • NOTARY PUBLIC / My Commission Expires: 9/ 709 ern•c% Notary Putt State Garret Cabrera arroro9 --- --- 4 {� My CommWlon EE129165 •ern 6 Expires09/11/2015 21 MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL Indemnification and Hold Harmless For Other Contractors and Subcontractors The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of County Commissioners from any and all claims for bodily injury (including death), personal injury, and property damage (including property owned by Monroe County) and any other losses, damages, and expenses (including attorney's fees) which arise out of, in connection with, or by reason of services provided by the Contractor or any of its Subcontractor(s) in any tier, occasioned by negligence, errors, or other wrongful act of omission of the Contractor or its Subcontractors in any tier, their employees, or agents. In the event the completion of the project (to include the work of others) is delayed or suspended as a result of the Contractor's failure to purchase or maintain the required insurance, the Contractor shall indemnify the County from any and all increased expenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification provided for above. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this agreement. 22 WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND NEW TRUMAN MEDICAL Prior to the commencement of work governed by this contract, the Contractor shall obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than: $100,000 Bodily Injury by Accident $500,000 Bodily Injury by Disease, policy limits $100,000 Bodily Injury by Disease, each employee Coverage shall be maintained throughout the entire term of the contract. Coverage shall be provided by a company or companies authorized to transact business in the state of Florida. if the Contractor has been approved by the Florida's Department of Labor, as an authorized self-insurer, the County shall recognize and honor the Contractor's status. The.Contractor may be required to submit a Letter of Authorization issued by the Department of Labor and a Certificate of Insurance, providing details on the Contractor's Excess Insurance Program. If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required. In addition, the Contractor may be required to submit updated financial statements from the fund upon request from the County. 23 GENERAL LIABILITY INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND NEW TRUMAN MEDICAL Prior to the commencement of work governed by this contract, the Contractor shall obtain General Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum: • Premises Operations • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability • Professional Liability • Expanded Definition of Property Damage The minimum limits acceptable shall be: $300,000 Combined Single Limit (CSL) If split limits are provided, the minimum limits acceptable shall be: $ 200,000 _per Person $ 300,000 per Occurrence $_50,000 Property Damage An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its provisions should include coverage for claims filed on or after the effective date of this contract. In addition, the period for which claims may be reported should extend for a minimum of twelve (12) months following the acceptance of work by the County. The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. 24 INSURANCE REQUIREMENTS Worker's Compensation $ 100,000 Bodily Injury by Acc. $ 500.000 Bodily Inj. by Disease, policy limits $ 100.000 Bodily In]. by Disease, each emp. General Liability, including $ 300,000 Combined Single Limit Premises Operation Products and Completed Operations Blanket Contractual Liability Personal Injury Liability Expanded Definition of Property Damage Professional Liability $250,000 per Occurrence and Including errors and omissions $750,000 Aggregate The Monroe County Board of County Commissioners shall be named as Additional insured on general liability policy. 25 New Truman Medical Agreement 2014 Attachment "A" NO. OF ATTACHED SHEETS: DATE OF EXAM IvsGUII.AL RLCORD I REPORT OF MEDICAL HISTORY NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons 1. NAME OF PATIENT(Last,first,middle) 2.IDENTIFICATION NUMBER T POS1[ion 4a. HOME STREET ADDRESS(Street or RFD;City or Town:State;and 2/P Codel 5.EXAMINING FACILITY 40.CITY c.STATE 4d.ZIP CODE 6. PURPOSE OF EXAMINATION 7. STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED(Use additional pages if necessary) a.PRESENT HEALTH b.CURRENT MEDICATION REGULAR OR INTERM. c.ALLERGIES(Include insect bites/stings and common foods) d.HEIbHI e.WEIGHT 8. PATIENT'S OCCUPATION 9.ARE YOU(Check one) Ei RIGHT HANDED 0 LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM ® NO DOQW CHECK EACH ITEM YES NO OKROW CHECK EACH ITEM YES NO DON'T NOW Household contact with anyone Shortness of breath Bone,join or other deformity with tuberculosis Pain or pressure in chest Los of finger or toe Tuberculosis or positive TB test Chronic cough Painful or"trick'shoulder Blood in sputum or when Palpitation or pounding heat or elbow coughing Heart trouble Recurrent back pain or any Excessive bleedingback in alter lnlury or High or low blood pressure NV dental work Cramps in your legs "Trick"or locked knee Suicide attempt or plans Frequent Indigestion Foot trouble Sleepwalking Stomach,liver or intestinal trouble Nerve Injury Wear corrective lenses - Eye surgery to correct vision - Lack vision in either eye la Jaundice or hepatitis Car,train,sea sickness Wear a hearing aid Broken bones Stutter or stammer Adverse reaction to medication Wear a brace or back support IIII Sion diseases Loss of mem ory or amnesia Scarlet fever Tumor,growth,cyst.cancer Nervous trouble of any sort Rheumatic feverME Hernia Periods of unconscmusness Swollen or painful jointsMI Hemorrhoids or rectal disease Parent/sibling with diabetes. Frequent or severe headaches Frequent or painful urination cancer,stroke or heart disease Dizziness or fainting spells Bed wetting since age 12 X-ray or other radiation therapy Eye trouble - Hearing loss Asbestos or toxic chemical Recurrent ear infections Sexually transmitted diseases exposure Chronic or frequent coldsIIII Recent gain or loss of weight Severe tooth or gum trouble Easy fdligability Sinusitis Been told to cut down or Hay fever or allergic rhinitis criticized for alcohol use Head miurN Used illegal substances Asthma 1.1 Thyroid trouble or goiter NSN 7540-00-181.0360 REV 6-981 Previous edition not usable Prescribed by SA FIRMA141 CFRI 201.9.2 024 I DATE OF EXAM MEDICAL RECORD REPORT OF MEDICAL EXAMINATION 1. LAST NAME-FIRST NAME-MIDDLE NAME 2. IDENTIFICATION NUMBER 3. Position 4. HOME ADDRESS(Number.sheet or RFD,city or town..Nate and ZIP Core) 5, EMERGENCY CONTACT(Name and address&contact 6. DATE OF BIRTH 7. AGE 8. SEX 9. RELATIONSHIP OF CONTACT n FEMALE IT MALE 10.PLACE OF BIRTH 11.RACE n WHITE n BLACK n ALASKA NAT DIAW r H ITENIC n HACK ICI ISLANDERCIFIC 12a,AGENCY 126.ORGANIZADON UNIT L I 13.TOTAL YEARS GOVERNMENT SERVICE a. MIUTARY b. CIVILIAN 14.NAME OF EXAMINING FACILITY OR EXAMINER,AND ADDRESS 15.RATING OR SPECIALTY OF EXAMINER 18.PURPOSE Of EXAMINATION 17.CLINICAL EVALUATION NUR- (Check each damM appgprala column,enter NE'lIno evaluated) ^M m% (Check each item*,appropriate column,enter'NE'✓nor evaluated) ^MAR. L A.HEAD,FACE,NECK AND SCALP O.PROSTATE(over O w clinically lndcated) B.EARS-GENERAL(INTERNAL CANALS) P.TESTICULAR (Auditory easi y under items 39 and 40) C.DRUMS(Penbralbn) R.ENDOCRINE SYSTEM D.NOSE S.CO SYSTEM E.SINUSES T.UPPER EXTREMITIES(SOen91h.ranged molbn) F M JTH AND THROAT U.FEET G.EYES-GENERAL Orme saes end xnect o under Gee 292A end na) V.LOWER EXTREMITIES(Except feel)(SOepM,range dmatbn) H.OPTHALMOSCOPIC W.SPINE,OTHER MUSCULOSKELETAL I. PUPILS(Rios*andmelbn) X.IDENTIFYING BODY MARKS,SCARS,TATTOOS J.OCULAR MOTILITY(Associated parallel rmvemm9 nysagmu$) Y.SKIN,LYMPHATICS K.LUNGS AND CHEST Z.NEUROLOGIC(Equilibrium tests under item 41) L.HEART(Thrust,,size.rhythm..sounds) AA.PSYCHIATRIC(Specity any personaliydeWStbn) _ _ M.VASCULAR SYSTEM(varicosities,etc.) • N.ABDOMEN AND VISCERA(Include hernia) NOTES: (Describe eeryabnomw4ly M detail. Enter pertinent Item number boom each comment. Continue M item 42 and use additional sheets IInecesary) 18.DENTAL(Placo appmpdate symbols,shown In examples.above or below number orupper and beer teeth.) REMARKS AND ADDITIONAL DENTAL X x x X ( X I DEFECTS AND DISEASES 0 qq Repmeble 2 y bnble 1 3 Mang 1 21 3 RegodcM 1 2 PaAal 31 ]3 Ted 52 ]l1 ]b ieeq 32 31 39 Teeth x 3II S) Dentures d2 X ) Fenr® R L I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 10 E H 32 31 30 29 20 27 26 25 24 23 22 21 20 19 18 17 7 T 19.TEST RESULTS(Copies of results are preferred as attachments) A.URINALYSIS: (1)SPECIFIC GRAVITY B.CHEST X-RAY OR PPD(Place,dote film number and result) 12)URINE ALBUMIN (4)MICROSCOPIC (3)URINE SUGAR C.SYPHILIS SEROLOGY(Spedy test used D.EKG E.BLOOD TYPE AND RH F.OTHER TESTS and malts) FACTOR NSN 7540.00-630 4038 STANDARD FORM 88(Rev.I0-94)(EG) 88(125 Prescribed by GSAIICMR FIRMR(41 CFR)201-9.202-1 Designed using Perform Pro,VNISIDOR,An 91 11.FEMALES ONLY DON'T DATE OF LAST MENSTRUAL DATE OF LAST PAP SMEAR DATE OF LAST MAMMO. CHECK EACH ITEM YES NO KNOW PERIOD GRAM Treated for a female disorder N/A N/A N/A N/A Change i menstrual pattern N/a CHECK EACH ITEM. IF'YE,. EXPLAIN IN BLANK SPACE TO RIGHT, LIST EXPLANATION BY ITEM NUMBER. ITEM YES NO 12.Have you been refused employment or been unable to hold a lob or iY, stay in school because of: i a.Sensitivity to chemicals,dust,sunlight.etc. b.Inab'iliiy to perform certain motions. c.Inabiiy to assume certain positions. d.Other medical reasons(If yes.give reasons.) 13. Have you ever been eated for a mental condition) (If yes,specify when, where,and give details.) 14.Have you ever been denied life insurance? Of yes,state reason end give details) 15. Have you had,or have you been advised to have,any operation. (If yes, describe and give age at which occurred.) 16.Have you ever been a patient in any type of hospital) fa yes, specify when, where, why,and name of doctor and complete address of hospital.) 17. Have you consulted or been treated by clinics.physicians,healers, illother practitionerswithin the past 5 years for other than minor nesses? n , e complete address of doctor,hospital,clinic,and derails.) 16. Have you ever been rejected for military service because of physical.mental,or other reasons? III yes,give date and reason for rejection.) 19.Have you ever been discharged from military service because of physical,mental,or other reasons? (If yes,give date,reason,and type of discharge:whether honorable,other then honorable.for unfitness or unsuitability.) 20. Have you ever received,is there pending,or have you ever applied for pension or compensation for existing disability? (O yes,specify what kind, granted by whom,and what amount,when,why.) 22. Have you ever been diagnosed with a learning disability) (If yes. give type, where,and how diagnosed.) 23. LIST ALL IMMUNIZATIONS RECEIVED I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors,hospitals. or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable by fine andlm imprisonment. 26a.TYPED OR PRINTED NAME OF EXAMINEE 26b.SIGNATURE 26c.DATE NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY". 25, PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA(Physician shall comment on all positive answers in Items 7 through II. Physician may develop by interview any additional medical history deemed important and record any significient findings here.) 26a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER 26b.SIGNATURE 26c.DATE STANDARD FORM 93 MEV.6.961 BACK • NAME IDENTIFICATION NUMBER NO.C£SHEETS ATTACHED MEASUREMENTS AND OTHER FINDINGS 20.HEIGHT 21.WEIGHT 22.COLOR HAIR 23.COLOR EYES 24.BUILD 25.TEMPERATURE RBLENDERn MEDIUM n HEAVY n OBESE 26.BLOOD PRESSURE(Ann eheart/Nell 27.PULSE(Ann at heart Intl) A SYS. B.RECUM- SYS . STANDING SYS. A.SITTING B.RECUMBENT C.STANDING O.AFTER EXERCISE E.2 MINS.AFTER SITTING DIMS, BENT DIAS. (S mins.) DIAS. (JmNa) 28.DISTANT VISION 29.REFRACTION 30.NEAR VISION RIGNT20/ CORR.TO20/ BY S. CX CORR.TO BY LEFT20/ CORR.TO20/ BY S. CX CORR.TO BY 31.HETEROPHORIA/NANO disIep ) ESO EXO RH. LH. PRISM DIV. PRISM CONY. CT PC PO 32.ACCOMMODATION 33.COLOR VISION(Test used and result) 34.DEPTH PERCEPTION UNCORRECTED RIGHT LEFT (Test abed and score) CORRECTED 35.FIELD OF VISION 35.NIGHT VISION(Test used and score) 37.RED LENS TEST 36.INTRAOCULAR TENSION RIGHT LEFT RIGHT LEFT 39.HEARING JO.AUDIOMETER 41.PSYCHOLOGICAL AND PSYCHOMOTOR(Tests used end score) RIGHT WN /155V /15 256 512500 511122 1024 2048 2896 4096 8G04444 81192 LEFT WN /15SV RIGHT 5 LEFT 42.NOTES(Continued)AND SIGNIFICANT OR INTERVAL HISTORY (Use addltbnal sheets✓necessary) 43.SUMMARY OF DEFECTS AND DIAGNOSES(lost diagnoses with Item numbers) 44.RECOMMENDATIONS-FURTHER SPECIALIST EXAMINATIONS INDICATED(Specify) 45A.PHYSICAL PROFILE P U L HES 46.EXAMINEE(Check) A.0 iS QUA`IFI`DFoR In accordance with attached job B. I IS NOT QUALIFIED FOR J 45B.PHYSIGLCATEGORY description 47.IF NOT QUALIFIED,LIST DISQUALIFYING DEFECTS BY ITEM NUMBER A B C E 40,TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE 49.TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE 50.TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN(Indicate which) SIGNATURE 51.TYPED OR PRINTED NAME OFREVIEMA NG OFFICER OR APPROVING AUTHORITY SIGNATURE STANDARD FORM BS(Rev 10-94)BACK nn OL ZCm m o ❑❑❑❑ mu ❑❑❑ at) n m Cif Zd , -1m co �T y ❑❑❑❑ ❑❑❑ ❑❑❑ o� h o m a o< g' E im ❑ x mm ❑ xn In - C m . m 8. 2 3 ma 8g 90 Jr O O < 5 a s w o� _ ! �I 03 N O d O ❑ 6 � a .Y :• •� � � a ro ow d o 33 = C a _ oo -' n t CO D c O n N o _Pi m - m < m s c mS m o 3a m o m �" o ,<d o2 - o n (D 3 = B m a 8 3 T O CD nS ry _a a m CO N 3 ^.N d CD b ., °' ry o N A o oo a H d 8 S N 3 .r y+.z .. m' 3 - 'm' a a C .- i N VI d _ 7 o d CO _ n O N C— N — N �Ji g co N 6 CO m 0 ?_Q N -St ID ❑ ❑❑❑❑❑ p C N �, I� Q a• 3 d H " kgd d rd xE 8 E . po 3 p O d C i' a - 0- ' N Z. 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New Truman Medical Agreement 2014 Attachment "C" Ll Evaluation Questionnaire To the employes Answers to questions in Section 1,and to question 9 in Section 2 of Part A.do nut require a medicalexamination. To the employee:Cart you read?(check oneb ❑Yes CI No Your employer must allow you to answer this questionnaire during normal working hours,or at a time and place that is convenient to you.To maintain your cothientj it .your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the healthcare professional who will review it. The following information must be provided by every employee who hat been selected to use any type of respirator(please print). NiII1e• Job Title Age(to nearest year): Sex(check one) Q Male O Female Date: Height feet_b>tes Weight lbs. Check the type ofrespir toryon will use(you can check more than one ategory): Phone number when you on be reached by the health a. ON,1Z or P le cam pemanwho reviews this Oncbid o e area non-cartridge type only). � �(��nra'k' The best time to call you at this number a. QOther type(for example half-or fug-6repiece type, pe twered-air purifying supplied-air,self-contained g apparahut Has your employer told you how to contact the health can Haveyouw ) _. person who will review this(check one): CI Yin QNo ... mPfmtor CI in ❑No If"Yee,"whattype(a): Part A— Section 2(Mandatory) Questions 1 though 9 below must be answered by every employee who has been selected to use any type of respirator (please check"yes"or"rn"). 1.Do you amenity smoke tobacco,or have you smoked tobacco in the last month? QYes QNo 2.Have you ever had any of the following conditions? a. Seizures(fib)< ........._..._..................._....._..._. .. QYes QNo b. Diabetes(sugar disease):_ QYes QNo e Allergic reactions that interfere with breathing .._..__.__.__.._.__. .. CI Yes ❑No d. Claustrophobia(fearpf closed-in places): ••••_..._ _.._..._.........__._.__. _ e. Tmubk smelling odors --......_...........__...__ QYes QNo 3.Have you ever had any of the foll owing pulmonary m lung pmbl ? CI Yet CI No ems. a. Asbestosis: b. Asthma: CI Yes QNo c Chronic bronchitis: ❑Yes QNo d. Emphysema: CI Yes QNo e. Pneumonia: ❑Yes CI No CI Y f. Tuberculosis: Dyes CI Noes . Sihcmie; •- Q yes CI No h Pneumdlnmx(collapsed lung) QYn QNo L Lung canny QYes Cl No j Broken tilts: CI Yes QNo k Any chest injuries or surgeries QYes 'QNo L An un QYes ONa Y other l 6pmblem flat you've beentold about...._.- 0Yes 0 No d.Do you currently have any of the following symptoms of pulmonary or lung fines? a. Shortness of breath: b. Shortness of breath when walking fast on level ground or welkin u astir OYes ONo .. Shortness of breath when walking with other people at anordinary P bhthillgroud: OYs ONo d. Have to stop for breath when walking at your own pace on levelvel gropundace on bvel yyourui. CI Yes ONo CI Yin ONo e. Shortness of breath when washing or dressing yourself. f. Shortness of breath that tnter' fers with vourjob: ❑Ys ONu g. Coughing that produces phlegm(thick sputumk • O Y1 s O No h. Coughing that wakes you early in the morning: O Yes O No i. Coughingthat occursOYs CI No mostly when you are lying down: OYs ONo j. Coughing up blood in the last month: Oyes No k. Wheezing ❑Yes ONo I. Wheezing that interferes withyourokr OYs. ONo m. Chest pain when you breathe deeply ❑Ys ONo n Any other symptoms that you think may be related to lung problems . CI Yes ONo 5.Have you ever had any of the following cardiovascular or heart problems? a. Heat aback b. Stroke CI Yes CI No e Angina: OYes OHo d. Heart failure CI Yes ONo e. Swellingin your legsor CI Yes ONo Yo (not aused by walking): ❑Ys ❑No f. Heart arhythmla(heatbstlng hregrdalyk .._._... .........,..._.._..__........_....�.,„„_O Yn_... O No g. Hngh blood pnseure•._. ......__ ..CI Yes ONo h. Any other heart problem thatyou've —.__....._._.__.._._ been told about CI Yes ONo i Have you ever had any of the following cardlovucular or heat sympton ? a. Frequent pain or lightness In your chestCI Yes ONo b. Pain or bghtnes in your chest during physical activity: ......._......................._._.._.__..__. ......._...._.._._._...._... ......... OYes ONoc Pain or s in chest that inttfsa with O Yes ❑No d. In thetwoyr .....—.._.._.._ past yeas, t you noticed to eating mishtga beaC__..r....._ CI Yes ❑No C. Heartburn or indigestion that b not related to eatlng _.._O Yes O No f. Any other symptoms that you think may be related to heart ordmdation problems CI Yes ONo 7.Do you currently take mediation fora y of the following problems? a. Breathing orlung problems:___...._..__ OYs ❑No b. Heart trouble- c Blood pressure OYes ONo d. Seizures(fib). CI Yes ONo ❑Yes O No 8.0 you'venseda napintoo have you ever had any of the following problems? ([f you've never used a respirator go to question 9) a. Eye britatiom b. Skin allergies or rashes OYa ONo c Anxiety ...._ OYs ONo d. General weakness or fatigue D yYes O No e. Otherproblem that ❑Ys O No interferes with yourrespiator use. 0Ys ❑No M%los•earl Oar IIIties 9.would you like to talk to the health cat.pmfessiond who will oarless this questionnaire about your .uswen to this questionnaire. ]Y,s No Qurstiuns 10 to IS below must be a nswend by every om plops:w ho has been si le.6'J too use Pother a lull-(a11'01V P respirator 1)r a self-co mtained breathing apparatus t5C8A).Foreemployws who hate been sett,toil hs use other typos of nspirdces.answering those yl°TlpMS IS voluntary. 10. Have you ever lost vision in either eye(temporarily or pemvrnentiy)n ']Yes ]No It. Do you currently have any of the following vision pmbleme? a. tYear cuntwt letwex b. Wear Oasts. ]Yro ONu e. Color blind. D Yes ]No J. ether eye or vision problem. OYn CI No ]Yro 7No 12 Have you ever bud an injury to your tan,Including a broken ear&tune Yes CI No 13.Dayms currently have any of the follmvtng hearing probtenr7 _ a. Difficulty hearing: b. Woar a hearing ad: ]Yro la No c. Any other hearing or ear problem: O Yoe ONo e No H. Have you ever had a back Injury• 7Yes ❑No 13.Do you cunendy have any of the following musanrloskeletal pmbleurr a. lYeuknes in any of your arms,hands,legs,or feet b. Back pain. OYes ONo c. Difficulty fully moving your arms and legs: OYs ONo J. Pain orstiffr lea when you n forward or backward at the waist CI Yee f]No e. Dtfieulty fully moving your head up or down: O Yes 0 No f. Difficulty fully moving your head side to side. O Yes 0 No g• Difficulty bending at your knees ❑Ya 0 No h. Difficulty squatting to the ground: CI Yes ❑No I. Climbing Nghtofstaies or LidJer 7Yel 7No carrying more than 2516e.• CI Yes ONo j. Any other muscle or skeletal problem that interfcr.s with using a aspirator 7Yes CI No Put B Any of the following questions,and other questions not listed,may be added to the questionnaire at the discretion of the health c—_ io-adwho will review the questionnaire. 1. En your portent job,are you working at high altitudes(over 5,000 feet)or in a place that has lower than nonral amounts of oxygen: or other symptoms when you're working under those conditions 7Yes CNo 7 Yes 7No L At work or at home,have you ever been exposed to haruJous solvents,hazidous airborne chemicals (e.g.gases,fumes,or Just),or have you come into skin contact with hazardous chemicahse r]Yes 7No RESPIRATOR USE PHYSICAL Name Age Sex Home Address Telephone Occupation Length of Employment I agree to the release of this information for State and Federal regulatory purposes to the extent provided by applicable laws. _._. DATE SIGNED _. _.. ❑Follow-up Medical Evaluation Physical EMPLOYER Required. (Positive response—Question 1-8). ❑Post-Offer Physical: Medical Evaluation Physical Required. . UC%liM.tlj Ose litiZIO • lace you ever worked with any of the materials,us under any of the conditions,Ihtcd below: AsissIns: YO% 3 No t . silk,:(oz.in gontllOasttnit,): t Ni, r44 ()kilt(14:. grinding or welding this in alma°. 'a VI'S a No J. tlorytkuln: 3 Yes No aluminum. 3 Yes 3 No V. C‘ Vor irtJ is on,tninso0 Its JNu g. from 3 Yts -I No Inv '3 Yes 3 No i. Dusty nosininments: -3 Yts 7 No j. Other hatinlous pisum: Yes 0 No if"yes"drunk;these exposunt 4.List any second jobs or side businesses you haves — 5.U.S your plevicuts occupations 6.List yourcuatent and previous hobbies; 7.Han you been in the milibuy services? 0 Yes CI No if"yes,"were you exposed to biologkal or dunned agents(either in training or combat) U Yes CI No &awe you everworked on a FIAMIAT team? 0 Yes 0 No 9.Other than medkations for breathing and lung problems,beast trouble,blood measure,and seizures mentioned earlier In this questionnaire,an you taking any other medications for any reason (including over-the-counter medicatiorn):. 0 Yes ONo "yts," name the medications if you know them: it Wal you be using any of the following items with your mpirator(s)? HEPA Filters 13 Yell '7 No Fs canisters(fur example.ltas masks). '3 Yes 13 No c. Cartrubss: r3 Vs '3 No I.flow often art you expected to use the nespirator(s)n J. Escape only(no wave) a Yes a No I. Emergency nave only Ytsa No Less than hours rer week: Ys 3 No U. Ls%Ulan 2 hour;pm day. yos a NO e. 2 hr.!hours rer tlar '3 Yts 7 No f. Os or.1 hour;Fur thy. Yes 13 No • 11CA bee.rN NIOBIUM 12. During the period you are using the respiratoris), is your work effort a. Light(Ins than}ill kcal per hour) ]Yw ]No II"yes," luuw long Jean this period last dune,the average shift: hit. ini re. Exampin o(a light we•rk"(fort are sitting while writing typing,drafting,or perfumhing light.rsr•mbly wr.,rk or standing in lute operating a Jnll pmss(1-3lbs.)or rontnilling ma.bin,,. N. \federate(]t)to lief kcal per hour). 7Ye+ ]No If"yes,"how long does this period last dung the average shill: hit._Mira. F_vampin of medrmte work titbit are sitting while nailing or filing,-driving..truck or bus in urban traffic;standing while drilling nailing, performing assembly work or transferring a Madrnkr load(JboutVS.lbs.)at trunk lec'b walking on a level surface about 2 mph or down a 1Kh4ie grade about 1 in ph;or pushing a wheelbarrow with a heavy load(about ill)lbs.)on a level surface. c. Heavy(above 331 kcal per hour):. . O Ye O No If"yes;'how lung shoes the period last during the average shift: ha_miro. Exampls of heavy work are lifting a heavy load(about 30 lbs.)from the door to your waist Cr shoulder,working on a loading disk shovelingy standing while bricklaying or chippingcastingr, walking up an 8-degree ggade about 2 mph climbing stairs with a heavy bad(about 30 Ref.). ---- 13.WM you be weanngprohayye dolliesa requ(pment(otherthan the respirator)when you're using your respirator DYce CI No if"yes,"describe this protective clothing and/or equipment 14.Will you be working under hot conditions(tempenlme exceeding 771*) O Yes O No 15 Will you be working under humid conditioner O Yes ❑No 17.Describe any special or hazardous conditioru you might encounterwhm you're using your respirator(s) (for crumple,confined spaces.Iifi-threatening gases): IS.Provide the following infomuton, if you know it,for each toxic substance that you'll be exposed to when you're sing your zespirator(s): Name of the first toxic substance: Estimated maximum etprnurc level ier shift: . • �vtG\Irre-wN as NUM Duration of espnure per shift Name.of the sitond tusk substance: Estimated maximum expsure level per shift Duration of expsun per shift — —�Name of the third toxic substance: Estimated maximum exposure level per shift Duration of exposure per ship The name of other toxic substances that you'll be exposed to while using your respirator 19.Describe any special responsibilities youll have while using your nesp rator(s)that may affect the safety and well-being of uthen(for example,rrscne,secarityk swath • irc.t fret .vie Rile imxm PLHCP Follow-Up Medical Examination employee Same: Copy of tarommendation given to employee IIyesc No Job title getommendatkoro about empby:e use tithe n'sptrator. Limitations- Date of this fellow-up: Reasons for follow-up Actions Need for follow-up medical evaluutiors- Date signed, - — Signed: Date givem • RESPIRATOR USE PHYSICAL See Attached Jab Description NAME AGE SEX HOME ADDRESS TELEPHONE OCCUPATION LENGTH OF EMPLOYMENT I agree to the release of this information for State and Federal regulatory purposes DATE SIGNED CARDIO-PULMONARY EXAMINATION I. HEIGHT WEIGHT 2. HEART: Murmen: Rate Rhythm Enlargement 3. LUNGS: Pulmonary Function Within Normal Limits Outside Normal Limbs 4. PA CHEST X-RAY: Within Normal Limits Outside Normal Limits S. RECOMMENDATIONS: It is my opinion that the above named patient is is not medically qualified to wear a Respirator in the performance of his/her duties. PHYSICIAN t7_l MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL 7. Use only safety type lathe dogs or those with flush set screws. 8. DO NOT HOLD emery cloth in your hand while polishing revolving work. Use a wood block or jig for this purpose. Only use files with handles. 9. When machine rods or bars that project beyond the head stock, enclose the projecting portion in a stationary pipe supported on a suitable stand. 10. The machining of irregularly shaped castings, crankshafts, and similar objects where the tool is not in contact with the work during the entire revolution of the chuck, IS EXTREMELY HAZARDOUS. The operator MUST BE CONSTANTLY ON THE ALERT to avoid being caught or struck by the work. 11. Do not knock chips off the tool or lean over the lathe to inspect the work while it is running. 10.17 PERSONAL PROTECTIVE EQUIPMENT A. Gloves: On operations where gloves are necessary, wear the proper type specified by your Supervisor. B. Hard Hats: Hard hats are provided by the County to protect your head against the danger of head injury from falling or flying objects, or from electrical shock and burns. Be sure your hat is in good condition and has a chin strap. There is no protection if the hard hat is knocked off. If an area is designated as "HARD HAT AREA" all persons entering these areas shall be required to wear a hard hat. C. Respirators 1. POLICY It is the policy of Monroe County to protect its employees from hazardous atmospheres through a comprehensive program of recognition; evaluation; engineering, administrative and work practice controls; and personal protective equipment, including respirators. To the greatest extent feasible, hazard elimination and engineering and work practice controls shall be employed to control employee exposure to within allowable exposure limits. However, where these measures are not feasible or fully effective or are under development, Monroe County shall provide appropriate respirators to affected employees under this program. Monroe County is committed to full compliance with applicable federal and state regulations pertaining to employee respiratory protection. 10-59 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL 2. PURPOSE The purpose of this program is to protect the health of Monroe County employees who may be exposed to hazardous atmospheres in the conduct of their work and to provide appropriate protection from these hazards, without creating new hazards. This program sets forth the County's practices for respirator use, provides information and guidance on the proper selection, use, and care of respirators, and contains requirements for establishing and maintaining a respirator program. 3. SCOPE This program applies to all Monroe County employees who need to wear a respirator to perform assigned duties. Examples of chemicals or operations that pose potential respiratory hazards and involve respirator use are Asbestos - Facilities Maintenance Dust— Facilities Maintenance & Roads & Bridges Spray Paint Operations— Fleet Management Immediate Danger to Life & Health (IDLH) — Fire Rescue Airborne/Bloodborne Pathogens— Fire Rescue Herbicides— Roads & Bridges, Airport Maintenance Household Waste—Solid Waste 4. ROLES AND RESPONSIBILITIES General Manager— Employee Services Director- Supports the Respiratory Protection Program and assigns a Respirator Administrator with responsibility and resources to administer the program. Respirator Administrator—Safety Officer- Has overall responsibility for the Respirator Protection Program including monitoring respiratory hazards, and conducting program evaluations. Has knowledge about respiratory protection and maintains an awareness of current regulatory requirements and good practices. Approves Respiratory Protection Programs for each operation that involves use of respirators. Approves training program for employees. 10-60 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL Approves fit test procedures for employees Approves respirator makes and models for use. Performs employee exposure monitoring upon initial work in a potentially hazardous atmosphere and whenever work conditions change that may affect employee exposure. Performs employee exposure monitoring in accordance with Federal and State OSHA regulations Uses generally accepted sampling techniques and analytical methods, including generally accepted quality assurance and control measures. Reports all findings to the supervisor within five days of receipt of analytical results from the laboratory, at a minimum. Upon request, performs surveys and makes recommendations for hazard control. Respirator Technician -Supervisor Complete initial respirator training, refresher training and maintain records. In addition, complete any recommended respirator manufacturer training prior to servicing respirators and their components. Perform and document semi-annual inspections of each air purifying respirator and monthly inspections of each supplied air respirator issued by the employer or maintained in its inventory. Ensure that compressed breathing air cylinders are hydrostatically tested on schedule. Remove from service and tagout any defective respirator parts. Perform maintenance and repairs for respiratory protection equipment in accordance with the manufacturer's instructions. Maintain an inventory of respirators and associated parts and equipment in a clean, secure area. Issue respirators when so directed in writing, inspecting to confirm that the respirator or equipment is of the type specified in the respirator plan or program. Issue spectacle kits to employees who require corrective lenses with their respirators. Perform tests for compressed air quality and inspect breathing air compressors periodically 10-61 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL Supervisors Initiate and approve a written Respiratory Protection Program for each operation that involves respirator use Complete the initial and respirator refresher training of the type attended by employees under their supervision Initiate safety briefings on respiratory protection issues at the start of each new project or task that involves respiratory hazards for affected employees under their supervision Ensure that any use of respirators by employees under their supervision is in accordance with this program and a written Respiratory Protection Program and Worksite-Specific Respiratory Protection Plan that has been approved by the Supervisor and the Respirator Administrator, or designee Record any complaints related to respirator usage, act promptly to investigate the complaints, correct any hazards, and get medical assistance, when indicated. Report first aid and medical treatment in accordance with Monroe County procedures. Report every respirator related incident to the Respirator Administrator before the end of the work shift Ensure that their employees have the requisite training, fit testing, and medical clearances before authorizing them to wear any respirators Prohibit any employee with lapsed or incomplete respirator clearances to work in hazardous atmospheres. Enforce any restrictions imposed by the occupational physician on individual employees, including the need for corrective lenses Physically check each respirator prior to its assignment to their employees to be sure that it is of the type specified in the written plan. Inform each affected employee of the results of exposure monitoring within one day of receiving such results and assure inclusion of all exposure reports in the County's recordkeeping system Monitor employee compliance with the respirator program requirements Employees Use respiratory protection in accordance with the instructions and training provide Immediately report any defects in the respiratory protection equipment and whenever there is a respirator malfunction, immediately evacuate to a safe area and report the malfunction 10-62 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL Promptly report to the supervisor any symptoms of illness that may be related to respirator usage or exposure to hazardous atmospheres Report any health concerns related to respirator use or changes in health status to the occupational physician Wash their assigned reusable respirators at the end of each work shift when used and disinfect assigned respirators at least weekly Store respirators in accordance with instructions received Observe any restrictions placed on work activities by the occupational physician. Be clean shaven in all facial areas that seal to the respirator face piece. Allow no headpieces, Band-Aids or other items beneath a respirator seal or head-strap assembly. Inspect the respirator immediately before each use, in accordance with training provided. Perform a user seal, negative and positive respirator fit check each time a respirator is donned in accordance with training provided. 5. PERMISSIBLE PRACTICE Any respirator worn by a Monroe County employee on the job shall be issued by Monroe County under this program. Respirators shall be issued by Monroe County and worn by exposed employees whenever airborne contamination levels are not otherwise reduced to within the allowable limits. A written Respiratory Protection Program and Worksite-Specific Respiratory Protection Plan shall be prepared and approved by the Supervisor and the Respirator Administrator prior to any employee respirator use, including voluntary usage or emergency use. This plan shall identify the location and tasks, identify and quantitative the air contaminants or oxygen deficiency, specify the appropriate respirator, and specify any limitations, such as air monitoring, respirator cartridge change out frequency, etc. Each operation involving respirator use must have a signed and approved written plan. Upon an employee's request, an appropriate respirator shall be issued for voluntary use when exposure to contaminant levels is at or above 50 percent of allowable limits, but within allowable limits, or when exposed to nuisance dusts, molds, pollen, etc. Reasonable efforts should be made to reduce such exposures. 10-63 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL Regardless of exposure level, employees who are exposed to any recognized carcinogen, mutagen or teratogen in the performance of their work assignments may request and receive an appropriate respirator for voluntary use and in addition, affected employees already assigned a respirator may request a respirator that provides a higher protection factor than the one provided by Monroe County for that work. The Monroe County Hazardous Material Emergency Response Plan required for chemical spills or releases, fire response, pathogen exposures, etc. shall include a Respiratory Protection Program and Worksite-Specific Respiratory Protection Plan whenever there is a reasonable potential for a respiratory hazard. The plan includes Monroe County's Fire Rescue, Public Works and Solid Waste response. At no time, however briefly, shall a Monroe County employee be exposed to contaminant levels that are more than three times the allowable 8-hour time- weighted average limits without respiratory protection No employee may work alone while wearing a respirator. Each respirator wearer shall have at least one employee assigned responsibility to perform periodic status checks throughout the duration of respirator use. When SCBAs are worn, at least one standby person, located outside of the hazardous atmosphere and equipped with an SCBA, shall be in constant attendance, ready to provide immediate assistance and to call for emergency help, if needed 6. Respiratory Protection Program and Worksite-Specific Respiratory Protection Plan Each operation that involves respirator use shall have a written Respiratory Protection Program and Worksite-Specific Respiratory Protection Plan that is approved and signed by the Supervisor and Respirator Administrator. This plan, which may be a part of a job hazard analysis, site safety plan, confined space entry permit or other document, shall contain an identification of the atmospheric hazard(s) and the respective measured or expected concentration(s) at each location or operation, the respective allowable concentration limits, the type of respirator(s) approved, monitoring requirements, emergency response procedures, and limitations, such as the frequency of respirator cartridge change-out. This document shall be updated annually and more frequently if conditions change. This document shall be available at the job location and shall be maintained for 30 years as an exposure record. 7. RECOGNITION AND EVALUATION OF AIRBORNE CONTAMINANTS A hazard assessment shall be initially performed in each workplace by the Supervisor or Respirator Administrator. Where the presence or potential presence of airborne to-64 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL contaminants is recognized or suspected the Respirator Administrator or other appointed evaluator shall perform evaluations to determine if allowable limits are exceeded or potentially exceeded. The results of the hazard assessment shall be communicated to the General Manager and affected supervisors and employees. For workplaces in which the hazard assessment produces no findings of potential exposures, Supervisors shall monitor the workplace and request a hazard assessment whenever materials or processes change. Whenever the hazard assessment identifies potential exposures to hazardous atmospheres, an annual reassessment shall be performed, unless a more frequent assessment is required by OSHA. In addition, the Supervisor is responsible for requesting a reassessment by the Respirator Administrator whenever materials or processes change. 8. EVALUATION OF AIRBORNE CONTAMINANT CONTROLS When hazardous atmospheres are recognized, elimination of the hazardous material or feasible engineering and work practice controls shall be instituted to reduce contaminant levels to within allowable limits. If such measures are not completely successful or if the condition is temporary, personal protective equipment, including respiratory protection shall be selected and worn. The Safety Officer shall reassess the workplace when controls are instituted to measure their effectiveness in reducing employee exposure to hazardous atmospheres. 9. SELECTION AND ISSUANCE OF RESPIRATORS Selection of the appropriate respirator shall be documented in the written Worksite-Specific Respiratory Protection Plan. If the atmosphere is uncharacterized, it must be assumed to be IDLH and a positive pressure SCBA or combination supplied-air respirator with SCBA must be worn. Respirator selection shall comply with OSHA requirements for specific substances, such as asbestos, lead, etc. At a minimum, the assigned protection factor of the selectee's respirator shall equal or exceed the hazard ratio. All respirators used by Monroe County employees shall be approved by NIOSH. No components shall be substituted, unless they are listed in the approval by NIOSH. Any change or modification to a respirator may void the respirator approval and may adversely affect its performance. Any restrictions or limitations recommended for a particular respirator by the respirator manufacturer shall be observed. The Supervisor shall inspect each respirator or component prior to issuance and shall assure that the respirator assembly is complete, sanitary and in good working order upon issuance. Atmosphere-supplying respirators shall be 10-65 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL returned to the Supervisor at least monthly for periodic inspection and air purifying respirators shall be returned for periodic inspection at least semi- annually. A log shall be maintained of these periodic inspections. The Supervisor is responsible to ensure that each respirator user under the Supervisor's supervision is currently approved for respirator use, including medical, fit testing and training certifications. Employees with expired certifications shall not be permitted to work in hazardous atmospheres or to voluntarily wear a respirator until their lapsed requirements are updated. Each respirator must be inspected by its wearer immediately prior to each use, according to instructions provided in the respirator training. Any defects shall be reported to the Supervisor before entry into a hazardous atmosphere. A user seal check shall be performed by the wearer immediately prior to entering the hazardous atmosphere. Monroe County will provide an appropriate spectacle kit to each respirator wearer who requires corrective lenses and will pay for prescription safety lenses for the kit initially and as needed. Contact lenses shall be permitted if the employee's ophthalmologist or optometrist authorizes their use by the employee in hazardous atmospheres with negative pressure and positive pressure respirators in a written communication to Monroe County Employees who are issued a respirator are responsible for its maintenance, daily inspection and storage while the unit is in their control. 10. FIT TESTING Each respirator wearer shall be fit tested, using protocols approved by the Respirator Administrator. Frequency testing shall be performed if required by the Federal Code of Regulations for specific substances or if the wearer's facial contours change, such as by weight gain or loss, facial surgery, etc. On the occasion of each fit test, employees may choose their respirator from an array of face pieces from different manufacturers and sizes approved by the Respirator Administrator. Fit test certifications shall be prepared and signed by the person performing the fit test and must name the tested employee; the make, model and size of respirator fit tested; and the result of the fit test. A copy shall be provided to the Supervisor. Monroe County required fit tests, including reasonable employee time and travel costs, shall be paid for by Monroe County. A medical evaluation as described in Section 10.17.C.11 must be performed before an employee is fit tested. 11. MEDICAL APPROVAL FOR RESPIRATOR USE 16-66 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL Each respirator wearer shall be approved for respirator use by the County's designated physician before the employee is required to wear a respirator (including before being fit tested). The physician shall be provided a copy of the employee's duties, respirator types to be worn, and air contaminants, as well as any applicable OSHA standards governing the medical evaluation, such as the Respiratory Protection standard and applicable substance-specific standards in addition to the Respirator Medical Evaluation Questionnaire to be completed by the employee being examined. The questionnaire shall be filled out by the employee confidentially during the employee's normal working hours or at a time and place convenient to the employee - preferably in the Human Resource office location nearest to the employee's worksite location. The physician's approval shall be a written certification that lists the respirator types approved for use by the individual (i.e., negative pressure air purifying, powered air purifying, pressure demand SCBA) and any restrictions on the employee's use of respiratory protection, including the need for corrective lenses. The physician's certification shall not disclose any confidential medical information, but shall clearly list or describe any restrictions to be observed. Medical evaluations shall be performed by the County's designated physician and the cost of the respirator medical evaluation shall be budgeted and paid by employee's department including reasonable time and travel expenses of the employee. Payment for special medical diagnostic procedures needed to assess the ability of an employee to safely wear a respirator shall be approved in advance by the Respirator Program General Manager. No medical treatment costs shall be paid by the employee under this program. Medical records created under this program shall be handled in accordance with requirements for confidentiality, employee access and retention If it is found that an employee is not physically able to wear a respirator, arrangements must be made by the applicable Supervisor and Department Head to have the duties associated with a respirator be performed by another qualified employee within the department. 12. TRAINING Each respirator wearer, supervisor of a respirator wearer, respirator technician and Officer must be trained and updated as needed. Upon successful completion of respirator training, the instructor shall sign a certification that names the employee trained, the type(s) of respirator and the training date. A copy shall be provided to the supervisor. A record shall be maintained of the training topics covered. 10.67 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL Monroe County approved respirator training shall be conducted by or paid for by Monroe County including the employee's reasonable time and travel to participate in such training. 13. DEFINITIONS Air purifying respirator(APR)—a type of respirator that removes specific contaminants from air by use of filters, cartridges or canisters by passing ambient air through the air-purifying element. APRs do not supply oxygen. Allowable limit—the maximum concentration of a substance in air that is permitted by regulation or voluntary standards to protect employee health. These concentrations may be expressed in terms of an 8-hour time-weighted average, a 15-minute short- term average or as an instantaneous upper ceiling limit. An example is the OSHA permissible exposure limits (PEL). Assigned protection factor—the level of respiratory protection expected to be provided by a given class of respirators to a properly fitted and trained user. This factor is assigned by OSHA in substance specific standards and by ANSI in the voluntary national standard, Z88.2. Atmosphere-supplying respirator—a type of respirator that supplies the user with breathing air from a source independent of the ambient atmosphere, and includes supplied-air respirators (SARs) and self-contained breathing apparatus (SCBA) units. Canister or cartridge—a container with a filter, sorbent or catalyst, or combination of these items, which removes specific contaminants from the air passed through the container. Demand respirator—an atmosphere-supplying respirator that admits breathing air to the face piece only when a negative pressure is created inside the face piece by inhalation. Dust mask—see filtering face piece. Emergency situation —any occurrence such as, but not limited to, equipment failure, rupture of containers, or failure of control equipment that may or does result in an uncontrolled significant release of an airborne contaminant. Employee exposure—exposure to a concentration of an airborne contaminant that would occur if the employee were not using respiratory protection. End-of-service-life indicator(ESLI)—a system that warns the respirator user of the approach of the end of adequate respiratory protection, for example, that the sorbent is approaching saturation or is no longer effective Escape-only respirator—a respirator intended to be used only for emergency exit. Filter or air-purifying element—a component used in respirators to remove solid or liquid aerosols from the inspired air. t0-68 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL Filtering face piece (Dust mask)—a negative pressure particulate respirator with a filter as an integral part of the face piece or with the entire face piece composed of the filtering medium. Fit factor—a quantitative estimate of the fit of a particular respirator to a specific individual, and typically estimates the ratio of the concentration of a substance in ambient air to its concentration inside the respirator when worn. Fit test— use of a protocol to qualitatively or quantitatively evaluate the fit of a respirator on an individual. Hazardous atmospheres—an atmosphere that contains a contaminant(s) in excess of the allowable limit or contains less than 19.5 percent oxygen. Hazard ratio—a number calculated by dividing the actual air contaminant concentration by the allowable limit. Immediately dangerous to life and health (IDLH)—an atmosphere that poses an immediate threat to life would cause irreversible adverse health effect, or would impair an individual's ability to escape from a dangerous atmosphere. Loose-fitting face piece—a respiratory inlet covering that is designed to form a partial seal with the face. National Institute for Occupational Safety and Health (NIOSH) —a Federal institute responsible for conducting research and making recommendations for the prevention of work-related illnesses and injuries. It tests and issues approvals for respirators. Negative pressure respirator(tight fitting) —a respirator in which the air pressure inside the face piece is negative during inhalation with respect to the ambient air pressure outside the respirator Occupational Safety and Health Administration (OSHA)—the Federal or state agency with authority to issue and enforce workplace health and safety regulations. Oxygen deficient atmosphere—an atmosphere with oxygen content below 19.5 percent by volume. Physician or other licensed health care professional (PLHCP)—an individual whose legally permitted scope of practice (i.e., license, registration or certification) allows him or her to independently provide or be delegated the responsibility to provide some or all of the health care services required by this respirator program. Positive pressure respirator—a respirator in which the pressure inside the respiratory inlet covering exceeds the ambient air pressure outside the respirator. 10-69 MONROE COUNTY SAFETY POLICIES AND PROCEDURES MANUAL Powered air-purifying respirator(PAPR) —an air-purifying respirator that uses a blower to force the ambient air through air-purifying elements to the inlet covering. Pressure demand respirator—a positive pressure atmosphere-supplying respirator that admits breathing air to the face piece when the positive pressure is reduced inside the face piece by inhalation. Protection factor—a ratio calculated by dividing the air contaminant concentration outside a respirator by the concentration inside the respirator. This is measured in a quantitative fit test. Qualitative fit test (QLFT) —a pass/fail fit test to assess the adequacy of respirator fit that relies on the individual's response to the test agent. Quantitative fit test (QNFT) —an assessment of the adequacy of respirator fit by numerically measuring the amount of leakage into the respirator. Respiratory inlet covering —that portion of a respirator that forms the protective barrier between the user's respiratory tract and an air-purifying device or breathing air source or both. It may be a face piece, helmet, hood, suit or a mouthpiece respirator with nose clamp. Self-contained breathing apparatus (SCBA)—an atmosphere-supplying respirator for which the breathing air source is designed to be carried by the user. Service life—the period of time that a respirator, filter or sorbent or other respiratory equipment provides adequate protection to the wearer. Supplied-air respirator(SAR) or airline respirator—an atmosphere- supplying respirator for which the source of breathing air is not designed to be carried by the user. Tight-fitting face piece—a respiratory inlet covering that forms a seal with the face. User seal check—an action conducted by the respirator user to determine if the respirator is properly seated to the face D. Foot and Toe Protection The appropriate foot protection is required for work functions that include lifting heavy objects that may be dropped on the feet, electrical protection, piercing protection, chemical protection, fire protection and working in areas that are designated as high hazard areas and require foot protection i.e.; around fork lifts and rolling stock. 10-70 New Truman Medical Agreement 2014 1582-1 Attachment "D" 7Mght 0 2000 NFPA,All Rights Reserved NFPA 158E Standard on Medical Requirements for Fire Fighters and Information for Fire Department Physicians 2000 Edition This edition of NFPA 1582,Standard on Medical Requirement for Far Fighters and Information for Ere Department Physicians,was prepared by the Technical Committee on Fire Service Occu- pational Medical and Health,and acted on by the National Fire Protection Association,Inc., at its November Meeting held November 14-17. 1999,in New Orleans,LA. It was issued by the Standards Council on January 14,2000,with an effective date of February 11,2000,and supersedes all previous editions. This edition of NFPA 1582 was approved as an American National Standard on February 11,2000. Origin and Development of NFPA 158E Ajoint task force ofinemben representing both the Technical Committees on Fire Service Occupational Safety and Health and Fire Fighter Professional Qualifications began address- ing medical requirements for fire fighten in March 1988.Astanding subcommittee on Med- ial/Physical Requirements for Fire Fighters was created under the Fire Service Occupational Safety and Health Committee in 1990 and was responsible for the development of NFPA 1582. This new document covered the medical requirements necessary for persons who perform fire-fighting tasks. Medical requirements that were previously contained in Section 2-2 of NFPA 1001,Standard for Fire Fighter Professional QuaAfscationr,applied only to the entry level. • They were deleted from NFPA 1001.Legal opinion and federal laws show that requirements set for a position must apply to anyone who would be or is in that position.These medical requirements are therefore intended to apply to candidates as well as to current fire fighters. Two categories of medical conditions were created,Categories A and B.Category A repre- sented conditions that,if they exist in the candidate or current fire fighter,would not allow this person to perform fire-fighting operations.Category B conditions must be evaluated on a case-by-case basis so that the fire department physician can determine if the medical condi- tion in a particular candidate or current fire fighter would prevent that person from perform- ing firefighting operations. Medical evaluations, medical examinations, record keeping, and confidentiality were addressed in Chapter 2.Chapter 9 contained the actual medical conditions that comprise the requirements. Extensive advisory and informational material was developed in the appendixes to aid fire department administrators and fire department physicians. The committee completed its work in January 1992,and the first edition was presented to the Association membenhip at the 1992 Annual Meeting in New Orleans,Louisiana. The second edition of this standard reflected the numerous changes in medical technol- ogy that have impacted structural fire lighten.The technical committee was assisted by phy- sicians whose expertise covered the areas of emergency medicine; vision: hearing; and cardiac,pulmonary,neurological,and metabolic conditions. The technical committee endeavored to update six critical areas and moved some of the previous Category A text to Category B.They then enhanced some of the Category Amaterial that would prohibit an individual from being hired or to continue as a fire fighter.The corn- ' mittee also added additional appendix text in the areas of ADA requirements,explanatory material for both fire department administrators and fire department physicians,and sample physician checklist(onus. Additional explanatory material was added or enhanced to provide the user with addi- tional information regarding medical conditions whose categories were changed. These included a number of cardiac conditions,diabetic conditions,seizure disorden,asthma,and , therapeutic anti-coagulation. 1582-2 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PH\SICUNS The 2000 edition of this standard reflects (I) the technical committee's recognition that medical technology is continually changing and (2) the committee's effort to incorporate F,those medical technology changes within the standard.Just as the committee recognizes med- ical technology advances,it is incumbent on the fire department to communicate with the fire department physician changes in the essential function(s) the fire department performs. Convenely,the fire department physician must keep the fire department updated on the lat- est changes in the medical field. Fire department physicians are the primary users of NFPA 1582.Committee memben feel that allowing the fire department physician more latitude in determination of a member's ability to perform essential functions will assist users in enforcing the standard.Therefore,the ;F committee has changed the title of the standard to NFPA 1582,Standard on Medical Recryin- ments for F tighten and Information for fire Department Physicians. The topic of incident scene rehabilitation and accountability are included in this edition, since the fire department physician may provide guidance or assistance at the rehabilitation unit. In addition, specific areas concerning the following conditions were clarified or expanded:cardiac,vision,hearing,neurological,and metabolic. �^ - An appendix was added to this edition comparing the requirements of this standard with those of 29 CFR 1910.134.the OSHA respiratory protection regulation.There are many users of both documents,and this appendix clarifies the companion areas of each. .v' a 2000 Edtan CONIMFiTEE PERSONNEL 1582_3 Technical Committee on Fire Service Occupational Medical and Health Marley E.Loftin,Chair Virginia Beach Fire Dept..VA(U) Rep.NFPA Fire Service Section David J.BarBlo,U.S.Army Inst.of Surgical Research. Deborah L Pritchett,Lawrence township Fire Dept.. TX(SEI IN(LI 14mberly S.Bens,BioCare,MI(SEI Rep.Indianapolis Metropolitan Professional Fire Paul"Short"Blake,City of Baytown Fire&Rescue Services. Fighters Union TX(El Gordon M.Sachs,IOCAD Emergency Services Group. Rep.Industrial Emergency Response Working Group PA(SEI UniversityMary S. Rep. Inc.Fire Co., Anthems LCat,KenonC County Airport OH(UI Daniel G. NH-OMEGA IL(SEI ThomasJ.Cuff,Jr.,Firemen Assn.of the State of New York.NY[U] JamesSewell,Seattle Fire Dept.,WA[LI Tatum DiAnda,Reno Fire Dept.,NV(Ul Rep.Intl Assn.of Fire Chief. John F.Falan, Reno Medical.Awoc.,NY(SEI Philip C.Stitdeourn,eer ear a Fire Dept,WI(LI Rep.Nat'l Volunteer Fire Council ' Richard D. ,Jr.,Good Samaritan Hospit/Phoenix Robert M.Smmrm District.a ,West Metro Fire Protection AZ Fire Dept.,AZ(El CO(RTI Juan Gonzalez,Medllex:The Exercise Science Inst. Rep,Metropolitan State College of Denver TX IRTI W.Larry Kenney,Penn State Univeniry,PA(Rill Andy C.Teeter,Tulsa FireDept,mininOKgAssoc. Awn. Sandra Kukwood,Inn Vegas Fire Dept,NV[Ul Kathy Tmioa,Cooperative Personnel Services,CA(SEI Frank P.Mitten,New York Ciry Fire Dept,NY[OI - Teresa Winn,Santa Ana College,CA[SEI Gary L Neilson,Truckee Meadows Fire Protection District Don N.Whittaker,Lockheed-Martin Idaho Technologies NV Co.,ID[El Rep.Fire Dept Safety Officers Awn. Dedter Williams.Phoenix Fire Dept..AZ(El Alternates David W.Dodson,Loveland Fire Dept.CO[Ul Thomas R.baby,New York City Fire Dept.,NY CUl (AIL eta G.L Neilson) (Alt to F.P.Minco) Michael S.Gray,Virginia Beach Fire Dept.VA(UI Brio V.Moore,Phoenix Fire Dept.,AZ[El (Alt.to M.E.Login) (Alt.to D.Williams) Stephen N.Foley,NFPA Staff Faison This reprewnb the membership at the time the Committer roar balloted on the find text of this edition.Since that time,changes in the membership may haw occumd.Aby to c4twiferaions is found at the back of the document. NOTE: Membership on acommince shall not in and ofinclfconsdwte an endorsement of theAssociation or any document developed by the committee on which the member serves. Committee Scope.This Committee shall have primary responsibility for documents on occupational medi- cine and health in the working environment of the fire service. 2000 Edfcn 1582-4 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PHYSICIANS Contents Chapter I Administration 1582- 5 3-18 Tumorsand Malignant Diseases 1582-10 r^ I-1 Scope 1582- 5 3-19 Psychiatric Conditions 1582-11 1-2 Purpose 1582- 5 3-20 Chemicals,Drugs,and Medications 1582-11 1-3 Implementation 1582- 5 14 Definitions 1582- 5 Chapter 4 Infectious Disease Program 1582-11 4-1 Infection Control Program 1582-11 ,i Chapter 2 Medical Process 1582- 6 4-2 Exposure Incidents 1582-11 2-I Medical Evaluation Process 1582- 6 2-2 Fire Department Roles 1582- 6 4-3 Tuberculosis 1582-I1 2.3 Preplacement Medical Evaluation 1582- 6 4-1 Immunizations 1582_1l 24 Periodic Medical Evaluation 1582- 7 2-5 Return-to-Duty Medical Evaluation 1582- 7 Chapter 5 Incident Scene Rehabilitation -26 Medical Evaluation Records,Results, and Medical Treatment 1582-11 Reporting,and Confidentiality 1582- 7 5-1 Incident Scene Rehabilitation 158E-11 5-2 Incident Scene Safety and Health 1582-11 Chapter 3 Category A and Category B 5-3 Evaluation and Triage of Medical Conditions 1582- 8 Member Injuries 1582-11 3-1 Medical Conditions Affecting Ability _ 5-4 Incident Scene Rehabilitation Tactical Level to Perform - 1582- 8 Management Component 1582-11 3-2 Head and Neck 1582- 8 3-3 Eyes and Vision 1382- 8 Chapter 6 Referenced Publications 1582-12 3-4 Ears and Hearing 1582- 8 3-5 Dental 1582- 8 Appendix A Explanatory Material 1582-12 3-6 Nose,Oropharynx,Trachea,Esophagus. and Larynx 1582- 8 3-7 Lungs and Chest Wall 158E- 9 Appendix B Information for Fire Department 3-8 Heart and Vascular System 1582- 9 Physicians 1582-21 k 3-9 Abdominal Organs and GastrGastrointestinaln 1582- 9 Append C Essential Structural Fire-Ftghdng Syste3-10 Genitourinary System 1582- 9 Function 1582-26 3-11 Spine,Scapulae,Ribs,and Sacroiliac Joints 1582-10 Appendix D Guide for Fire Department 3-12 Extremities 1582-10 Administrators1582-26 3-13 Neurological Disorders 1582-10 3-14 Skin 1582-10 Appendix E Sample Forms 1582-33 315 Blood and Blood-forming Organs 1582-10 3-16 Endocrine arid Metabolic Disorders 1582-10 Appendix F Referenced Pubbcadoos 1582-33 3-17 Systemic Diseases and Miscellaneous Conditions 1582-10 Index 1582-48 -. 2000 Baton AOStIMsTlt rION 1582-5 NFPA 1582 14 Definitions. 14.1• Approved. Acceptable to the authority having juris- Standard on diction. 14.2• Authority Having Jurisdiction. The organization, Medical Requirements for Fire Fighters and office. or individual responsible for approving equipment. Information for Fire Deparunent Physicians materials,an installation.or a procedure. 1-1.3` Candidate. A person who has made application to 2000 Edition commence performance as a member. 14.4 Category A Medical Condition. A medical condition that NOTICE: An asterisk('I following the number or letter den would preclude a person from perforating as a member in a ignating a paragraph indicates chat explanatory material on training or emergency operational environment by presenting dm paragraph can be found in Appendix A. a significant risk to the safetvand health of the person or others. Information on referenced publications can he found in 14.5 CategoryB Medical Condition. A medical condition Chapter and Appendix F. that,based on its severity or degree,could preclude a person from performing as a member in a training or emergency Chapter I Administration operational environment by presenting a significant risk to the safety and health of the person or others. 1-1 Scope. 14.6 Drug. Any substance,chemical,over-the-counter medi- I-1.1 This standard shall contain medical requirements for cation.or prescribed medication that could affect the perfor- members,including MI-time or pan-time employees and paid mince of the member. or unpaid volunteers.It also shall provide information forphy- 14.7 Essential Job Function. Task or assigned duty that is sicians regarding other areas of fire department medicine, critical to successful performance of the job. including infection control and fireground rehabilitation. 14.8 Evaluation. See Medical Evaluation. 1-1.2 These requirements are applicable to public.govemmen- 14.9 Exposure Incident. A specific eye, mouth, or other ed,military,private,and industrial fire department organizadons mucous membrane. non-intact skin, or parenteral contact providing rescue,fire suppression,emergency medical services. with blood,body fluids.or other potentially infectious materi- hazardous materials mitigation,special operation, and other als. or inhalation of airborne pathogens. ingestion of food- emergencyservices borne pathogens or toxins. 1-1.3 This standard shall not apply to industrial fire brigades 1-4.10 Fire Department Physician. The licensed doctor of that also can be known as emergency brigades. emergency medicine or osteopathy who has been designated by the fire response teams.fire teams,plant emergency organizations,or department to provide professional expertise in the areas of mine emergency response teams. occupational safety and health as they relate to emergency services. 1-2 Purpose. 14.11 Functional Capacity Evaluadon. An assessment of the 1.2.1 The purpose of this standard shall be to specify mini- correlation between that individual's capabilities and the mum medical requirements for candidates and current mem- essential job functions. ben. It also shall provide other information regarding fire 14.12 Health and Fitness Coordinator. The person who,under department activities that assist the department physician in the supervision of the fire department physician.has been desig- providing proper medical support for members. natal by the department to coordinate and be responsible for 1.2.2* The implementation of the medical requirements out- the health and fitness programs of the department.11ted in this standard shall help ensure that candidates and 14.13 Health and Safety Officer. The member of the fire current members are medically capable of performing their department assigned and authorized by the fire chief as the required duties and shall help to reduce the risk of occupa- manager of the safety and health program and who performs tional injuries and illnesses. the duties and responsibilities specified in this standard.This individual can be the incident safety officer or that can also be 1-2.3 Nothing herein shall be intended to restrict anyjurisdic- a separate function. don from exceeding these minimum requirements. 14.14 Infection Control Officer. The person or persons 1-3 Implementation. within the fire department who'are responsible for managing the department infection control program and for coordinat- 1-3.1 For candidates, the medical requirements of this stan- ing efforts surrounding the investigation of an exposure. dard shall be implemented when this standard is adopted by 14.15 Infection Control Program. The fire department's lor- an authority havingjurisdiction.on an effective date specified mal program relating to the control of infectious and commu- by the authority having jurisdiction. nicable'disease hazards where employees, patients, or the I-3.2• When this standard is adopted by a jurisdiction, the general public could be exposed to blood, body fluids, or authority having jurisdiction shall set a date or dates for cur- other potentially infectious materials in the fire department rent members to achieve compliance with the requirements work environment.This program includes,but is not limited of this standard and shall be permitted to establish a phase- to,implementation of written policies and standard operating in schedule for compliance with specific requirements of this procedures regarding exposure follow-up measures, immuni- standard in order to minimize personal and departmental rations, members' health screening programs, and edua- disruption. tional programs. 2OW Edition 1552-6 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFOR%L\TION FOR FIRE DEP.\RTMMENT PHYSICIANS 14.16 Medical Evaluation. The analysis of information for 2-2 Fire Department Roles. the purpose of making a determination of medical certifica- tion. Medical evaluation can include a medical examination. 2-2.1 The Fire department shall have an officially designated 14.17 Medical Examination. An examinationperformed or physician who shall be responsible for guiding,directing,and advising the members with regard to their health,fitness,and directed by the fire department physician. suitability for duty as required by NFPA 1500,Standar!on Fin 14.18 Medical Services. Emergency. The provision of treat- apartment Occupational Safety am!Health Program ment—such as first aid, cardiopulmonary resuscitation.basic 2.2.2. The fire department physician shall be a licensed doe. life support,advanced life support,and other pre-hospital pro- cedures including ambulance transportation—to patients. tor of medicine or osteopathy. 14.19 Medically Certified A determination by the fire depart- 2-2.3• For the purpose of conducting medical evaluations. men[physician that the candidate or current member meets the the fire department physician shall understand the physiolog- medical requirements of this standard cal and psychological demands placed on members and shall 14.Y0• Member. A person involved in performing the duties understand the environmental conditions under which mem. and 0 Member. of a fire department.iunder the auspices ben must perform.The fire department shall provide the fire department positions with of the organization.A fire department member can be a full- and a ranks.n job description for all Fire time or part-time employee or a paid or unpaid volunteer,candepartment positions ks. occupy any position or rank within the fire department,and 2-2.4 The fire department shall require that the fire depart- can engage in emergency operations. ment health and safety officer and the health and fitness coor- dinator maintain a liaison with the fire department physician ber and whose duties require the performance of essential to ensure that the health maintenance process for the fire fire-fighting functions. department is maintained. 14.21 ShalL Indicates a mandatory requirement. 2-2.5 Fire Department Physician Roles. 14.22 Should. Indicates a recommendation or that which is 2-2.5.1 The fire department physician shall evaluate the per- advised but not required. son to ascertain the presence of any medical conditions listed 14.23 Standard. A document, the main text of which con. in this standard. tains only mandatory provisions using the word"shall"to indi- 2-2.5.2 When medical evaluations are conducted by a physician cart requirement and which is in a form generally suitable for other than the fire department physician,the evaluation shall mandatory reference by another standard or code or for adop- p rS1 be reviewed and approved by the fire deparan<n[physician.don into law.Nonmandatory provisions shall be located in an appendix,footnote.or fine-print note and are not to be con- 2-3* Preplacement Medical Evaluation.sidered a part of the requirements of a standard. • 2d•1 The candidate shall be certified by the fire department 14.24 Tactical Level Management Component (TLMC). A management unit identified in the incident management sys- physician as meeting the medical into requirements of Chapter 3 ram commonly known as"division,""group,"or"sector." of this e a dard prior to entering into a training program to become a member or performing in an emergency opera- tional environment as a member. Chapter 2 Medical Process 2-3.2 The candidate shall be evaluated according to the med- 2-1 Medical Evaluation Process. kcal requirements of Chapter 3 of this standard to assess the effect of medical conditions on the candidate's ability to per- 24.lv The fire department shall establish and implement Form as a member. a medical evaluation process for candidates and current 2-3.3 A candidate shall not be certified as meeting the medi- members. cal requirements of this standard if the fire department physi- 2-1.2 The medical evaluation process shall include preplace clan determines that the candidate has any Category A ment medical evaluations, periodic medical evaluations•and medical condition as specified in Chapter 3 of this standard. return-to-duty medical evaluations. 2-3.4v A candidate shall not becertifiedas meeting the med- ical requirements of this standard if the fire department phy- - 2-1.3 The fire department shall ensure that the medical eval- uation process and all medical evaluations meet all of the sician determines that the candidate has a Category B requirements of Section 2.1. medical condition as specified in Chapter 3 of this standard that is of sufficient severity to prevent the candidate from 2-1.4 Each candidate or current member shall cooperate.par- performing,with or without reasonable accommodation,the ticipate.and comply with the medical evaluation process and essential functions of a member without posing a significant shall provide complete and accurate information to the fire risk to the safety and health of the candidate or others. department physician. 2-3.4.1 The determination of whether a reasonable accom- 2.1.5• Each candidate or current member shall report,on a modation shall be made by the authority h urisdiction in timely basis,to the fire department physician any exposure or conjunction with the fire department physician. medical condition that could interfere with the ability of the 2-3.5 If the candidate present with an acute medical problem individual to perform as a member, or newly acquired chronic medical 2-1.6 The medical evaluation shall be ac no cost to the candi- with the candidatescondition ability perform the functions ofa mem- date,current member,or other member. ber.medical certification shall be postponed until that person 2000 E®tiara MEDICAL PROCESS 1382-7 has recovered from this condition and presents to the fire physician determines that the member has a Category B con- department for review. dition specified in Chapter 3 of this srauukud that is of suffi- cient severity to prevent the member from performing,with or 24' Periodic Medical Evaluation. without reasonable accommodation,the essential functions of 24.1 The current member shall be certified annually, or at a member without posing a significant risk to the safety and the request of either the fire department or the member, by health of the member or others. the fire department physician as meeting the medical require- 24.3.1 The determination of reasonable accommodation ments of Chapter 3 of this standard in order to determine that shall be made by the authoriry having jurisdiction in co junc- member's medical ability to continue participating in a train- non with the fire department physician. ing or emergency operational environment as a member.Any applicable OSHA standards,such as 29 CFR 1910.120, *Hat- 24.4 If the current member presents with an acute illness ardous Waste Operations and Emergency Response:29 CPR or recently acquired chronic medical condition.the evalua- 1910.134.`Respiratory Protection,"29 CFR 1.910.95."Occupa- tion shall be deferred until the member has recovered from tional Noise Exposure,"and 29 CPR 1910.1030,"Bloodbome the condition and presents to the fire department to return Pathogens,"shall be followed, to duty. 24.1.1 The components of the annual medical evaluation as 2.3 Return-to-Duty Medical Evaluation. specified in 24.1.2 shall be permitted to be performed by qualified personnel as authorized by the tire department 2-3.1' A current member who has been absent from duty for physician.When other qualified personnel are used.the fire a medical condition of a nature or duration that could affect department physician shall review the data gathered during performance as a member shall be evaluated by the fire the evaluation. department physician before returning to duty. 24.1.2 The annual medical evaluation shall consist of the fol. 2-5.2 The fire department physician shall not medically cer- lowing tify the current member for return to duty if any Category A (I) An interval medical history medical condition specified in Chapter 3 of this standard is (2) An interval occupational history. including significant present. exposures 2-5.3* The fire department physician shall not medically cer- (3) Height and weight tify the current member for return to duty if any Category B (4) Blood pressure medical condition specified in Chapter 3 of this standard is (5) Heart rate and rhythm present that is determined to be severe enough to affect the 24.1A' In addition tothe annual medical evaluation,the fire members performance as a member. The fire department -department shall include a medical examination according to physician, in conjunction with the authority having jurisdic- th e following schedule lion,shall take into account the member's current duty assign- ment and alternative duty assignments or other programs that (1) Ages 29 and under—at least every 3 years would allow a member to gradually return to full duty. 12) Ages 30 to 39—at least every 2 years (3) Ages 40 and above—every year 2-5.4* The department shall provide guidance,opportunity, and encouragement to the member so as to expedite his safe 24.1.4* The medical examination shall include examination return to full duty. of the following components: (1) Vital signs—namely,pulse,respiration,blood pressure. 26 Medical Evaluation Records,Results,Reporting,and and,if indicated.temperature Confidentiality. (2) Dermatological system 2-6.1 All medical information collected as part of a medical (3) Ears,eyes,nose,mouth,throat evaluation shall be considered confidential medical informa- f4) Cardiovascular system don and shall be released by the fire department physician (5) Respiratory system only with the specific written consent ofthecandidateorcur- (6) Gastrointestinal system rent member. (7) Genitourinary system (9) Endocrine and metabolic systems 26.2 The fire department physician shall report the results of (9) Musculcskeletal system the medical evaluation to the candidate or current member, (10)Neurological system including any medical condition(s)disclosed during the med. (11)Audiometry cal evaluation, and the recommendation as to whether the (12)Visual acuity and peripheral vision testing candidate or current member is medically certified to perform (13) Pulmonary function testing as a member. (14)Laboratory testing,if indicated 2-6.3 The fire department physician shall inform the fire (15)Diagnostic imaging,if indicated department fire chief or designee only as to whether or not (16) Electrocardiography,if indicated the candidate or current member is medically certified to per- 24.2 A current member shall not be certified as meeting the form as a member.The specific written consent of the candi- medical requirements of this standard if the fire department date or current member shall be required in order to release physician determines that the member has any Category A confidential medical information regarding this condition to medical condition specified in Chapter 3 of this standard. the fire department. 24.3' A current member shall not be certified as meeting the 24.4 All medical record keeping shall comply with the medical requirements of this standard if the fire department requirements of 29 tFR 1910.20,"Medical Recordkeeping.' 2000 Erman 1562-A MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEP.VRT%IENT PHYSICIANS Chapter 3 Category A and Category B 34 Ears and Hearing. Medical Conditions • 3.4.1 There shall be no Category A medical conditions. 3-1 Medical Conditions Affecting Ability to Perform. Cate- 3-42' Category B medical conditions shall include the fol- gory A and Category B medical conditions shall help the lowing: examiner understand the type of condition that could result (a) Hearing deficit in the pure tone thresholds in the in rejection or acceptance.The medical conditions listed are unaided wont ear that is organized by organ system.In the corresponding Appendix A explanatory material,a diagnostic example is often included (1) Greater than 25 dB in three of the four frequencies with the list.In addition,the rationale for the rejection is pre- a. 500 Hz seated in terms of the effect of the medical condition on the b. 1000 Hz capability of the person to perform as a member. c. 2000 Hz 3-2 Head and Neck d. 3000 Hz OR 3-2.1 Head. (2) Greater than 30 dB in any one of the three frequencies 3-2.1.1 There shall be no Category A medical conditions. b 100 tr" b. 1000 Hz 3-2.1.2* Category B medical conditions shall include the fol- c. 2000 Hz lowing: AND (I) Deformities of the skull such as depressions or exostoses (3) In addition avenges greater than 30 dB for the four fro- (2) Deformities of the skull associated with evidence of dis- qu<ncies ease of the brain,spinal cord,or peripheral nerves a. 500 Hz b. 1000 Hz (3) Lou or congenital absence of the bony substance of the c. 2000 Hz skull d. 3000 Hz (4) Any other head condition that results in a person not (b) Unequal hearingloss being able to perform as a member 9 (c) Aeoia,severe stenosis,or tumor of the auditory canal 3-2.2 Neck. (d) Severe externalotitis 9-2.P.1 There shall be no Category A medical conditions. (e) Severe agenesis or traumatic deformity of the auricle (t) Severe mastoiditu or surgical deformity of the mastoid 3-2.2.2' Category B medical conditions shall include the fol- (g) Meniere's syndrome or labyrinthitis lowing (h) Otitis media (1) Thoracic outlet syndrome (i) Any other ear condition that results in a person not being able to perform as a member and results in a person (2) Congenital cysts, chronic draining fistulas, or similar being unable to pass a job-specific functional hearing task test lesions or a hearing in noise test. (3) Contraction of neck muscles (4) Any other neck condition that results in a person not 3-5 DentaL being able to perform as a member 3-5.1 There shall be no Category A medical conditions. 33 Eyes and Vision. 3-5.2' Category B medical conditions shall include the fol- owing 3.3.1' Category A medical conditions shall include the fol- (1) Diseases of the jaws or associated tissues lowing: (2) Orthodontic appliances (a) Far visual acuity.Far visual acuity shall be at least 20/30 (3) Oral tissues,extensive loss binocular, corrected with contact lenses or spectacles. Far (4) Relationship between the mandible and maxilla that pre- visual acuity uncorrected shall be at least 20/100 binocular for dudes satisfactory postorthodontic replacement orabil- wearers of hard contacts or spectacles. ity to use protective equipment (5) Any other dental condition that results in a person not (b) Peripheral vision.Visual field performance without cor- being able to perform as a member rection shall be 140 degrees in the horizontal meridian in each eye. 3-6 Nose,Oropharyns,Trachea,Esophagus,and Laryvx. 3-3.2' Category B medical conditions shall include the fel- 3-6.1° Category A medical conditions shall include the fol- lowing: lowing (1) Diseases of the eye such as retinal detachment, progres- (I) Tracheostomy sive retinopathy,or optic neuritis (2) Aphonia (2) Ophthalmological procedures such as radial keratotomy 3.6.2' Category B medical conditions shall include the Col- or repair of retinal detachment lowing: (3) Any other eye condition that results in a person not being (1) Congenital or acquired deformity able to perform as a member (2) Allergic respiratory disorder -_ 2000 Edition CATEGORY AND CATECORYB MEDICAL CONDITIONS 1582-9 (3) Sinusitis,recurrent 3-8.2 Vascular System. (4) Dysphonia 38.2.1 There shall be no Category A medical conditions. (5) Anosmia (6) Any other nose,oropharynx.trachea,esophagus,or lar- 3-8.2.2* Category B medical conditions shall include the fol. ynx condition that results in a person not being able to lowing: perform as a member or to communicate effectively (1) Hypertension (2) Peripheral vascular disease such as Rnynaud's phenome- 3-7 Lungs and Chen Wall. non 3-7.1" Category A medical conditions shall include the fol- (3) Recurrent thrombophlebitis lowing: (4) Chronic lymphedema due to lymphadenopathy or severe venous valvular incompetency (1) Active hemoptysis (5) Congenital or acquired lesions of the aorta or major yes- (2) Empyema sels (3) Pulmonary hypertension (6) Marked circulatory instability as indicated by onhostatic (4) Active tuberculosis hypotension, persistent tachycardia, and severe periph- eral vasomotor disturbances 3-7.2" Category B medical conditions shall include the fob (7) Aneurysm of the heart or major vessel lowing: (8) Any other vascular condition that results in a person not (1) Pulmonary resectional surgery,chest wall surgery,pneu- being able to perform as a member mothorax (2) Bronchial asthma or reactive airways disease 3-9 Abdominal Organs and Gastroinmstinal System. (3) Fibrothorax,cheat wall deformity,diaphragm abnormalities 3-9.1 There shall be no Category A conditions. (4) Chronic obstructive airways disease - 3-9.2" Category B medical conditions shall include the fol- (5) Hypoxemic disorders lowing: (6) Interstitial lung diseases (q Cholecystitis (7) Pulmonary vascular diseases,pulmonary embolism (2) Gastritis (8) Bronchiectasis (3) GI bleeding (9) Infectious diseases of the lung or pleural space (4) Acute hepatitis (10)Any other pulmonary condition that results in a person (5) Hernia not being able to perform as a member (6) Inflammatory bowel disease 3-8 Heart and Vascular S (7) Intestinal obstruction ystem. (8) Pancreatitis 38.1 Heart. (9) Resection,bowel (10)Ulcer,gastrointestinal 38.1.1" Category A medical conditions shall include the fol- (11)Cirrhosis.hepatic or biliary lowing: (12)Chronic active hepatitis (1) Angina pectoris,current (13)Any other gastrointestinal condition that results in a per- (2) Heart failure,current son not bring able to perform the duties of member (3) Acute pericarditis.endocarditis,or myocarditis 3-10 Genitourinary System. (4) Syncope,recurrent (5) Automatic implantable cardiac defibrillator 5-10.1 Reproductive. 34.1.2° Category B medical conditions shall include the fol- 3-10.1.1 There shall be no Category A medical conditions. lowing 3-10.1.2* CategozyB medical conditions shall include the fol- (1) Significant valvular lesions of the heart,including pros- lowing: thetic valves (1) Pregnancy,for its duration (2) Coronary artery disease,including history of myocardial (2) Dysmenorrhea infarction, coronary artery bypass surgery, or coronary (3) Endometriosis,ovarian cysts,or other gynecologic con- angioplasty,and similar procedures ditions • (3) Atrial tachycardia,flutter,or fibrillation (4) Testicular or epididymal mats (4) Left bundle branch block,second-and third-degree atri- (5) Any other genital condition that results in a person not oventricular block being able to perform as a member (5) Ventricular tachycardia 3-10.2 Urinary System. (6) Hypertrophy of the heart (7) Recurrent paroxysmal tachycardia3-10.2.1 There shall be no Category A medical conditions. (8) History of a congenital abnormality 3-10.2.2* Category B medical conditions shall include the fol. (9) Chronic pericarditis,endocarditis,or myocarditis lowing (10)Cardiac pacemaker (1) Diseases of the kidney (1l)Coronary artery vasospasm (2) Diseases of the ureter,bladder,or prostate (12)Any other cardiac condition that results in a person not (3) Any other urinary condition that results in a person not being able to perform as a member being able to perform as a member 2000 Edeon 1582-la MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPART).TENT PH\SICLLNS 3-1l Spine,Scapulae,Ribs,and Sacroiliac Joints. 3-14 Skin. 3-11.1 There shall be no CategoryA medical conditions. 3-14.1 There shall be no Category A medical conditions. 111.2• Category B medical conditions shall include the fel- 314.2• Category B medical conditions shall include the fol- lowing. lowing: (I) Arthritis (I) Acne or inflammatory skin disease (2) Structural abnonnaliry,fracture,or dislocation (2) Eczema (3) Nucleus pulpoms. herniation of. or history of laminec- (3) My other dermatologic condition that results in the per- [omy.disceaomy or fusion son not being able to perform as a member (4) Ankylosing spondylius 3-15 Blood and Blood-Forming Organs. (5) Any other spinal condition that results in a person not beingablemperformas a member g 3-15 1' Category A medical conditions shall include the FM- lowing: 112 Extremities. (I) Hemorrhagic states requiring replacement therapy 3-12.1 There shall be no Category A medial conditions. (2) Sickle cell disease (homozygous) 3-12.2' Category B medical conditions shall include the fol- 1152' Category B medical conditions shall include the fol- e lowing lowing: (I) Limitation of motion of a joint (I) Anemia (2) Amputation or deformity of a joint or limb (2) Leukopenia (3) Dislocation of a joint (3) Polycydsemia van (4) Splenomegaly (4) joint reconstruction, ligamentous instability, or joint (5) History of thromboembolic disease replacement (6) Any other hematological condition that results in a per- (5) Chronic osteoarthritis or traumatic arthritis son not being able to perform as a member (6) Inflammatory arthritis (7) Any other extremity condition that results in a person not 3-16 Endocrine and Metabolic Disorder. being able to perform as a member X 3-16.1• Diabetes mellitus,which is treated with insulin or an oral hypoglycemic agent and where an individual has a history 113 Neurological Disorders. of one or more episodes of incapacitating hypoglycemia,shall 3-13.1' Category A medical conditions shall include the fol- be a Category A medical condition. lowing: 3-16.2' Category B medical conditions shall include the fol-- (I) Ataxias of heredo-degenerative type lowing:(2) Cerebral arteriosclerosis as evidenced by documented (1) Diseases of the adrenal gland, pituitary gland. panthy- episodes of neurological impairment roid gland,or thyroid gland of clinical significance (3) Multiple sclerosis with activity or evidence of progression (2) Nutritional deficiency disease or metabolic disorder within previous three years (3) Diabetes mellitus requiring treatment with insulin or oral (4) Progressive muscular dystrophy or atrophy hypoglycemic agent without a history of incapacitating (5) All epileptic conditions to include simple partial,complex hypoglycemia partial, generalized, and psychomotor seizure disorders (4) Any other endocrine or metabolic condition that results other than those with complete control during previous in a person not being able to perform as a member • five years.normal neurological examination,and defini- 3-17 Systemic Diseases and Miscellaneous Conditions. five statement from qualified neurological specialist. 3-13.2 If an epileptic member experiences a five-year seizure- 117.1 There shall be no Category medical conditions. free interval resulting from a change in the medical regimen, 3-17.2• Category B medical conditions shall include the fol- that individual shall not be cleared for return to fire-fighting lowing: duty until he or she has completed five yean without a seizure on the new regimen. (I) Connective tissue disease,such and heuuatoida tits,lupus eryiduals ohm,scleroderma ad rheumatoid arthritis 3-13.3' Category B medical conditions shall include the fol- (2) Residuals from past thermal injury lowing: (3) Documented evidence of a predisposition to heat stress (1) Congenital malformations with recurrent episodes or resulting residual injury (2) Migraine (4) Any other systemic condition chat results in a person not being able to perform as a member (3) Clinical disorders with paresis, paralysis, dyscoordina • - don,deformity,abnormal motor activity,abnormality of 3-18 Tumors and Malignant Diseases. sensation,or complaint of pain 118.1 There shall be no Category A medical conditions. (4) Subarachnoid or intracerebral hemorrhage (5) Abnormalities from recent head injury such as severe 3-18.2• Category B medical conditions shall include the fol- cerebral contusion or concussion lowing: (6) Any other neurological condition that results in a person (1) Malignant disease that is newly diagnosed,untreated,or not being able to perform as a member currently being treated. 2000 E61ion INCIDENT SCENE REIAsILITATION AND MEDICLL TREATMENT 1582_Il a. Candidates shall be subject to the provisions of 2-3.5 43.2• MI members shall be evaluated according to current of this standard. CDC guidelines following any tuberculosis exposure. These b. Current members shall be subject to the provisions of results shall be communicated to and reviewed by the fire 24.4 of this standard- department physician. (2) Treated malignant disease that is evaluated on the base 44* Immunivtiov. All members shall be immunized of an individual's current physical condition and on the against infectious diseases as required by the authority basing likelihood of the disease to recur or progress. 6 (3) Any other or similar condition that results in a per- jurisdiction and by 29 CFR physician1030 shall"Blo ensurelbor Patho- son not othertng able to perform as a member. gees.' The fire department that all members are offered currently recommended immunizations. 3-19 Psychiatric Conditions. 3-19.1 There shall be no Category A medical conditions. Chapter 5 Incident Scene Rehabilitation 3-19.2• Category B medical conditions shall include the fol- and Medical Treatment lowing. 5-1 Incident Scene Rehabilitation. (1) A history of psychiatric condition or substance abuse problem 51.1• The fire department shall develop standard operating (2) Any other psychiatric condition that results in a person procedures that outline a systematic approach for the rehabil- no[being able to perform as a member itation of members operating at incidents. Provisions addressed in these procedures shall include medical evalua- 3-19.3 Candidates and current members shall be evaluated don and treatment,food and fluid replenishment,crew rota- based on the individual's current condition. don,and relief from extreme climatic conditions. 3-20 Chemicals,Drugs,and Medications. 5-1.2" The incident commander shall consider the circum- stances of each incident and initiate rest and rehabilitation of 3-20.1 There shall be no Category A medical conditions. members in accordance with the fire department's standard 3-20.2' Category B medical conditions shall include the use operating procedures and with NFPA 1581,Standard on Dram- of the following: gnny Services Incident Management System, (1) Anticoagulant agents 5-2 Incident Scene Safety and Health. (2) Cardiovascular agents 52.1 The incident safer/officer shall ensure that the incident (3) Narcotics commander establishes an incident scene rehabilitation cacti- _(4) Sedative-hypnotics cal level management component during emergency open- (5) Stimulants dons as required by NFPA 1521, Standard for Fire Department (6) Psychoactive agents Safety Officer. (7) Steroids (8) Any other chemical,drug,or medication that results in a 52.2• Transport capable emergency medical services (EMS) person not being able to perform as a member shall be available in the incident scene rehabilitation tactical level management component for evaluation and treatment of members. Basic life support (BLS) shall be the minimum level of available care. Advanced life support (ALS) care is Chapter 4 Infectious Disease Program preferable where it is available. 41 Infection Control Program. 5-3 Evaluation and Triage of Member Injuries. 41.1 The fire department shall maintain infection control 5-3.1 In the event of an injury too member during emergency programs as delineated in NFPA 1581,Smndani an Fire Depart- operations, EMS personnel shall assess and treat the injury matt Infection Control Program based on local EMS protocol and fire department standard 4-1.2 The fire department physician shall maintain a liaison operating procedures. with the infection control officer as specified in NEPA 158E 5-3.2• Protocols and procedures guiding EMS providers car. 4-2 Exposure Incidence ing for ill or injured members during emergency operations shall be developed by the EMS medical director in collabon- 4-2.1" All blood and/or body fluid exposures shall be don with the fire department physician and chief. reported immediately, and medical assessment shall be pro- vided within 2 hours of exposure. Medical assessment shall 54 Incident Scene Rehabilitation Tactical Level Management conform to current CDC guidelines. Component. 4-2.26 All other exposure incidents shall be reported and 5-4.1 The rehabilitation tactical level management comps- assessment provided within 24 hours of exposure. nent shall be designated per department standard operat- ing procedures,such as large-scale incidents,long-duration 4-3 Tuberculosis. incidents,or those associated with significant temperature 4-3.1• The fire department shall provide a tuberculosis mon- extremes. itoring program that will test members at least annually and as 54.2 The rehabilitation tactical level management compo- indicated by CDC guidelines.Tuberculosis (TB) testing inter- nent shall be established in a safe environment away from the vals shall conform to current CDC guidelines. hazardous area of the incident 2000 Edition 1582-12 MEDICAL REQ0IREHENTS FOR FIRE FIGHTERS AND INFORfIATION FOR FIRE DEP.\RTMENT PH\SICI.3NS 54.3• The resources needed at the rehabilitation tactical Appendix A Explanatory Material level management component shall include an environment to limit temperature street,medical equipment,and adequate ,appendix A is not a part of the requirements of Chu hFPA docu. medical stiff rent but is included for informational purpasa only. This appendix 54.4• Members shall be assigned to rehabilitation as pre- containsexplanatory material, numbered toramespond meth she appli. scnbed by departmental standard operating procedures. cable text paragraphs. Unusual circumstances,such as long-duration incidents.situa- tions requiring heavy exertion, or severe weather extremes A-1-2.2 There is a direct relationship between the medical shall require an alteration in procedures. requiremenrs and the job description of members. The job description should include all essential job functions of mem- 54.5• Members arriving at rehabilitation shall be briefly ben.both emergency and nonemergency. Members perform questioned by medical staff about any symptoms of dehy diet a variety of emergency operations including tire fighting, tion,heat stress.cold stress,physical exhaustion.and/or car- emergency medical care,hazardous matenals midynlion,and diopulmonary abnormalities.Any member having signiticant special operations.Nonemergeny duties can include,and are symptoms shall be moved to an area where assessment by not limited to.training,station and vehicle maintenance,and advance life support personnel can be performed. physical fitness. Each fire department needs to identify and 54.6 Members assigned to rehabilitation shall be encouraged develop a written job description for members. Appendix C. ' to add/remove clothing to regain normal body temperature. Essential Fire-Fighting Functions. provides an example of drink fluids (water,electrolyte replacement drinks).and rest. essential job functions for members. 3-17 No member shall he reassigned to return to dun'until A-I-3.2 The specific determination of the authority having medical evaluation and hydration has occurred for at least jurisdiction depends on the mechanism under which thisstan- 10 minutes in rehabilitation and after being cleared by dard is adopted and enforced.Where this standard is adopted medical staff. voluntarily by a particular fire department for its own use,the authority having jurisdiction should be the fire chief or the 54.8 All members entering and leaving rehabilitation shall be political entity that is responsible for the operation of the fire properly assigned by the incident management system and be department. Where this standard is legally adopted and tracked through the personnel accountability system. enforced by a body having regulatory authority over a fire department. such as federal. state, or local government or Chapter 6 Referenced Publications political subdivision,this body is responsible for making those Pdeterminations as the authority having jurisdiction.The com- pliance program should take into account the services the fire 6-I The following documents or portions thereof are refer- department is required to provide, the finandal resources enced within this standard as mandatory requirements and available to the fire department,the availability of personnel, shall be considered pan of the requirements of this standard. the availability of trainers,and such other factors as will affect The edition indicated for each referenced mandatory docu- the fire department's ability to achieve compliance. men(is the current edition as of the date of the NEPA issuance of this standard.Some of these mandatory documents might A-I4.1 Approved. The National Fire Protection Association also be referenced in this standard for specific informational does not approve, inspect,or certify any installations, proce- purposes and,therefore,are also listed in Appendix F. dures,equipment,or materials; nor does it approve or evalu- atebl.l NFPA Publications. National Fire Protection Associa- testing laboratories. In determining the acceptability of don. I Baaerym cat Park.P.O.Box Fire Quincy,MA 02269- installations,procedures,equipment,or materials,the author. iry having jurisdiction may base acceptance on compliance 1500, Standard on Fins Department Occupational Safety with NFPA or other appropriate standards.In the absence of and Health Rrogmm, 1997 edition. such standards,said authority may require evidence of proper installation,procedure,or use.The NFPA 1521. Standard for Fire Apnrtmmz Safety O/fun 1997 authority rac jurisdic- ti edition. d practices may also refer to the listings or labeling practices of an NFPA I561,Standard¢n Era Services(Maidens Mann organization that is concerned with product evaluations and e EmergencyManage- thus in a position to determine compliance with appropriate melt System,2000 edition. standards for the current production of listed items. NFPA 1581.Standard on Fin Department Infection Contra(Pro- gram.2000 edition. A-I4.2 Authority Having Jur sdicfron. The phrase"authority 6-i.i U. Government PubBntions. U.S.Government Print- manner,jurisdiction' is used in NFPA documents in a broad ing Office.Washington.DC 20401. manner,since jurisdictions and approval agencies vary,as do Tide Codeashi gton.f Federal Lttimu,Part 1910.120,"Huzad- their responsibilities. Where public safety is primary. the ous Waste Operations and Emergency Response,"1986. authority haying regionalepar jurisdiction may be a federal,lsuchstate,retal.o; other sl:c iefartmert or individual such as a fire chief; Title 29.Code ofFederal Regu[a<i�ms,Part 19I0.174."Respite- fire marshal:chief of a ire prevention bureau,labor depar[- tory Protection," 1998. ment, or health department; building official; electrical Tide 29, Code of Federal Regulations,Pan 1910.95, "Occupa' inspector,or others having statutory authority.For insurance tional Noise Exposure: 1980. purposes,an insurance inspection department.rating bureau. Title 29. Code of Federal Regulations, Part 1910.20."Medical or other insurance company representative may be the author- Recordkeeping,'1980. ity having jurisdiction. In many circumstances, the property Title 29, Code of Federal Regulations,Part 1910.1030."Blood- owner or his or her designated agent assumes the role of the horn Pathogens, 1995. authority having jurisdiction;at government installations,the 2010 Edition APPENDIX A 1582_13 commanding officer or departmental official may be the A-2-5.3 See Appendix D.Section D-I,Legal Considerations in authority havingjurisdicdon. Applying the Standard. A-I4.3 Candidate. In an employment context, the Ameri- A-2-5.4 Physical therapy, strength training, work hardening, cans with Disabilities Act(discussed in further detail in Appen- functional capacity evaluations,and alternate dory are all activ. dix DI requires that anv medical examination to be conducted hies that can be helpful. rake place after an offer of employment is made and prior to 422.1 Category B medical conditions of the head include the commencement of duties.Therefore,in the employment the following: context,the definition of the term candidateshould be applied so as to be consistent with that requirement. (1) Deformities of the skull. such as depressions or exos- Volunteer members have been deemed to be employees roses,of a degree that interferes with the use of protec- in some states or jurisdictions. Volunteer fire departments rive equipment. Deformities of the skull can result in should seek legal counsel as CO their legal responsibilities in the member's inability to properly wear protective these matters. equipment. A-14.20 Member. See Appendix C.Essential Structural Fire- (2) Deformities of the skull associated with evidence of dis- FightingFunetions. ease of the brain,spinal cord,or peripheral nerves.These deformities can result in the potential for sudden Inca- A-2-1.I See Appendix D.Guide for Fire Department Adminis- pacitation. the inability to properly wear protective uators. equipment,and the inability to communicate effectively due to oropharyngeal dysfunction. 42-1.5 Exposures and medical conditions that should be (3) Loss of or congenital absence of the bony substance of the reported if they can interfere with the ability of the individual skull (if associated with disease interfering with perfor- to perform as a member include, but are not limited to,the mance or ifappropriate protection cannot be provided for followings the area without interfering wits protective equipment (1) Exposures to hazardous materials or toxic substances and vision).Loss of or congenital absence of the bony sub- (2) Exposure to infectious or contagious diseases stance of the skull can result in the inability to properly (3) Illness or injury wear protective equipment and the inability to communi- (4) Use of prescription or nonprescription drugs sate effectively due to oropharyngeal dysfunction. (5) Pregnancy (4) Any other head condition that results in a person not being able to perform as a member. A-2-2.2 See Appendix D.Section D-"_,Choosing a Fire Depart- ment Physician. A-3-2.2.2 Category B medical conditions of the neck include the following: - A-2-2.3 See Appendix B. Information for Fire Department Physicians. Appendix C, Essential Structural Fire-Fighting (1) Thoracic outlet syndrome (symptomatic).Thoracic out- Functions provides a generic description of job tasks per- let syndrome can result in frequent episodes of pain or formed by members.A fire department needs to provide the inability to perform work. fire department physician with ajob description of all posi- (2) Congenital cysts, chronic draining fistulas. or similar dons and ranks so that the fire department physician can lesions (if lesions or underlying disease interferes with understand the physical and mental demands placed upon all performance). Congenital cysts, chronic draining fistu- members regardless of position or rank.Appendix D,Guide las,or similar lesions can result in the inability to properly for Fire Department Administrators, also provides guidance wear protective equipment,and the inability to commu- for ensuringthat the fire department physician is provided nicate effectively due to oropharyngeal dysfunction. with this information. (3) Contraction of neck muscles(if it interferes with wearing A33 See Appendix B, Section B-3, Guidance for Medical of protective equipment or ability to perform duties). Ppe^ The contraction of neck muscles can result in the inabil. Evaluations. icy to properly wear protective equipment,and the inabil- A-2-3.4 See Appendix D.Section D-I,Legal Considerations in icy to perform functions as a member due to limitation of Applying the Standard. flexibility. (4) Any other neck condition that results in a person not A.24 See Appendix B. Section B-3. Guidance for Medical being able to perform as a member. Evaluations. A-3-3.1 Category A medical conditions of the eyes and vision A-24.L3 At the discretion of the fire department physician, include the following: - an-examination can be performed sooner than would be expected from the schedule given in 24.1.3.Current medical (1) Far visual acuity.Far visual acuity is at least 20/30 binocu- conditions and coronary risk factors could mandate more fre- lar,corrected with contact lenses or spectacles.Far visual quent medical examinations_ acuity uncorrected is at least 20/100 binocular for wear- ersof hard contacts or spectacles. Successful long-term A-24.L4 See Appendix B,Guide for Fire Department Phy- soft contact lens wearers (that is. six months without a sicians. problem) are not subject to the uncorrected standard. A-24.3 See Appendix D.Section D-.I,Legal Considerations in Inadequate far visual acuity can result in the failure to be Applying the Standard. able to read placards and street signs or to see and respond to imminently hazardous situations. A-2-5.I A department should set protocols regarding length (2) Peripheral vision.Visual field performance without correc- of time absent from duty and/or medical conditions that lion is 140 degrees in the horizontal meridian in each require the department physician to evaluate a member. eye. (Members cannot have just monocular vision.) 2000 Edition 1581-14 MEDICALREQUIREMENTS FOR FIRE FIGHTERS OD INEOIiLA Ilom FOR FIRE DEPARTMENT PIDSICIANS Monocular vision can result in sudden incapacitation (b) Severe external otitis,that is,recurrent loss of hearing when debris is lodged in one eye.Inadequate or coinpro- can result in the inability to hear sounds of low intensity or to - mised peripheral vision can result in the following: distinguish voice from background noise,leading to failure to a. Failure to perform job duties and maintain visual con- respond to imminently hazardous situations.cut with a partner (c) Severe agenesis or traumatic deformity of the auricle b. Inability to maintain safety near moving objects can result in the inability to properly wear protective equip- c. Poor balance on uneven surfaces nmen[and the inability to hear sounds of Inv intensity or to dis- d. Unsuccessful performance in environmeno where nguixh voice from background noire, leading to failure to visual cues are critical to personal safety respond to imminently hazardous situations. (d) Severe nsastoiditis or surgical deformity of the mastoid A-3-3.2 Category B medical conditions of the eyes and vision can result in the inability to properly wear protective equip include the following: ment and the inability to hear sounds of low intensity or to dis- (I) Diseases of the eve such as retinal detachment, progres- tinguish voice from background none, leading to failure to sive retinopathg or optic neuritis(severe or progressive). respond to imminently hazardous situations. These diseases of the eve can result in the failure to read (e) Meniere s syndrome or severe labvtinthitis may result placards and street signs or to see and respond to immi- in the potential for sudden incapacitation and the inability to nentiv hazardous situations. perform job functions due to limitations of balance. (2) Ophthalmological procedures such as radial keratot- (0 Otitis media (chronic)can result in frequent episodes omv and repair of retinal detachment. With retinal of pain or the inability to perform work and the inability to detachment, sufficient time (1-2 weeks for radial kera- hear sounds of low intensity or to distinguish voice from back- tonomy and Lasik-type surgeries,three months for red- ground noise,leading to failure to respond to imminently haz- nal detachment) must have passed to allow stabilization ardous situations. of visual acuity and to ensure that there are no posrsilr- gicai complications. These ophthalmological proce- (g) An other ear condition that results in i person - may result in the failure to be able to read being able todi perform as a memberrican be classified as a Cat- duresplacards and street signs or to see and respond to immi- nently egory B medical condition of hearing. hazardous situations. A-3-5.2 Category 8 dental medical conditions include the fol- (3) Any other eye condition that results in a person not being lowing: able to perform as a member.Persons with severe color (U Diseases of the jaws or associated tissues (those that are vision loss will likely fail the acuity requirement. incapacitating or preclude ability to use protective Formerly, color vision deficiency was listed as a Cate- equipment). Diseases of the jaws or associated tissues gory B medical condition. However,it is felt that within can result in the inability to properly wear protective most cases this condition will not affect the ability of a equipment. member to perform the essential functions of his or her job.The fire service physician should consider the color (2) Orthodontic appliances (those that preclude the ability vision deficiency of the individual and consider the color to use protective quip ent).Thewearingofnerlywen- vision requirements of the members Job and reach an tic appliances can result in the inability to properly wear individual determination. protective equipment. (3) Oral tissues,extensive loss (that which precludes sasisfac- A-34.2 There are currently no hearing tests that will allow the tory postorthodontic replacement or ability to use pro- fire department physician to accurately predict whether the tective equipment). Extensive loss of oral tissues may fire fighter will adequately be able to perform essential job result in the inability to properly wear protective equip- duties.Job-specific hearing tests should be individualized for ment and the inability to communicate effectively due to each department and its specific job functions.The following oropharyngeal dysfunction. list ofhearing-specific tasks can assist to direct development of (4) Relationship between the mandible and ma.'olla that pre- hearing protocols. dudes satisfactory postorthodontic replacement or abil- (1) Understanding spoken commands, both over the radio ity to use protective equipment.This condition can result and while wearing SCBA in the inability to properly wear protective equipment (2) Hearing alarm signals, including building evacuation, and the inability to communicate effectively due to low air signal on the SCBA.and PASS alarms oropharyngeal dysfunction. (31.Hearing and locating the source of calls for assistance (al Any other dental condition that results in a person not from victims or other fire fighter being able to perform as a member. All of the above tasks will need to be performed with rea- A-3b.1 Category A medical conditions of the nose,orophar- sonably simulated incident scene background noise and SCBA ynx,trachea esophagus,and larynx include the following: noise.The inability to hear sounds of low intensity or to diain- (I) Tracheostomy.A tacheostomy can result in the inability guish voice from background noise can lead to failure to to properly wear protective equipment, the inability to respond to imminently hazardous situations. (See also fi25.) perform job functions due to limitations of endurance, Category B medical conditions of hearing include the for- and the inability to communicate effectively due to lowing: oropharyngeal dn function. (a) Unequal hearing can result in the inability to localize (2) Aphonia,a, regardless of cause.Aphonia can result in the sounds,leading to failure in the ability to perform search and inability to communicate effectively due to oropharyn- rescue and other localization tasks. pal dysfunction. 2OW Eeilpn APPENDIX A 1582-13 A.3.8-2 Category II medical conditions of the nose, orophar- (9) Infectious diseases of the lung or pleural space. vnx.trachea,esophagus.and larynx include the following: (10)Any other pulmonary condition that results in a person (1) Congenital or acquired deformity that interferes with the not being able to perform as a member. ability to use protective equipment. A congenital or A-3-&1-1 Category A medical conditions of the heart and vas. acquired deformity can result in the inability to properly cular system include the following wear protective equipment (2) Allergic respiratory disorder(uncontrolled).Allergic res (1) Angina pectoris. current. Angina pectoris can result in piratory disorder can result in frequent episodes of pain, frequent episodes of pain or inability to perform work, the inability to perform work.and the inability to perform progressive illness leading to functional impairment,and functions as a member due to limitations of endurance. the potential for sudden incapacitation. (3) Sinusitis, recurrent (severe, requiring repeated hospital- (2) Heart failure, current. Mean failure can result in frc. izations or cawing impairment). Recurrent sinusitis can quent episodes of pain or inability to perform work,pro- gressive illness leading to functional impairment,and the result in frequent episodes of pain and the inability to perform work. potential for sudden incapacitation. (4) Dysphonia (severe). Severe dwphonia can result in the (3) Acute pericarditis. endocarditis, or mvocarditis. These conditions can result in frequent episodes of pain or the inability to communicate effectively due to oropharvn- geal dysfunction inability to perform work. (5) Any other nose,oropharvnx, trachea,esophagus,or lar- (4) Syncope, recurrent.Recurrent syncope can result in the vnx condition that results in a person not being able to potential for sudden incapacitation. perform as a member or to communicate effectively. (5) Automatic implantable cardiac defibrillator. Anauto- matic implantable cardiac defibrillator can result in the A-3.7.1 Category A medical conditions of the lungs and chest potential for sudden incapacitation. wall include active hemoptysis, empvema, pulmonary hyper- tension,and active tuberculosis.These conditions can result A-3-8.1.2 Category B medical conditions of the heart and vas- in the inability to perform functions as a member due to limi- cular system include the following: cations of endurance. (1) Significant valvular lesions of the heart,including pros- A-3-7.2 Category B medical conditions of the lungs and chest thetic valves.Specific recommendations include the EoI- wall include the following: lowing: (1) Pulmonary resectional surgery,chest wall surgery,pneu- a. .Nina/stenosis Mittel stenosis is acceptable if in sinus mothorax (that is. history of recurrent spontaneous rhythm and stenosis is mild,that is,valve area>1.5 cm= pneumothorax). These conditions can result in the or pulmonary artery systolic pressure<95 ram Hg. inability to perform functions as a member due to limita- b. Mitral insufficiency.Missal insufficiency is acceptable if dons of strength or endurance and may result in the in sinus rhythm with normal left ventricular size and potential for sudden incapacitation. function. (2) Bronchial asthma or reactive airways disease (frequent c. Aortic srrnwis Aortic stenosis is acceptable if stenosis medication use or symptoms caused by exposures to exer- is mild, that is, mean aortic valvular pressure gradi- tion,heat and cold.or products of combustion and other ent<20 ram Hg. - irritant inhalation).Bronchial asthma or reactive airways d. Aortic regurgitation.Aortic regurgitation isazceprable if disease can result in frequent episodes of pain or the left ventricular size is normal or slightly increased and inability to perform work,the potential for sudden inca- systolic function is normal. pacitation, and the inability to perform functions as a e. Prosthetic valves.Prosthetic valves are acceptable unless member due to limitations of endurance full anticoagulation is in effect (5) Fibrothorax,chest wall deformity,diaphragm abnormali- (2) Coronary artery disease including history of myocardial , ties. Fibrothorax, chest wall deformity, and diaphragm infarction, coronary artery bypass surgery, coronary abnormalities can result in the inability to perform Cunt- angioplasty, and similar procedures. Persons at mildly dons u a member due to limitations of endurance increased risk for sudden incapacitation are acceptable (4) Chronic obstructive airways disease.Chronic obstructive for fire fighting. Mildly increased risk is defined by the airways disease can result in the inability to perform tune- presence of each of the following: dons as a member due to limitations of endurance. a. Normal left ventricular ejection fraction (5) Hypoxemic disorders.Hypoxemic disorders can result in b. Normal exercise tolerance,>10 metabolic equivalents the inability to perform functions as a member due to (METS) limitations of endurance, c. Absence ofexercise4nduced ischemia by exercise testing (6) interstidal lung diseases. Interstitial lung diseases can d. Absence of exercise-induced complex ventricular result in the inability to perform functions as a member arrhythmias due to limitations of endurance. e. Absence of hemodynamically significant stenosis on all (7) Pulmonary vascular diseases, pulmonary embolism. Poi- major coronary arteries ( 0 percent lumen diameter monary vascular diseases and pulmonary embolism can narrowing),or successful myocardial revascularizadon result in frequent episodes of pain and the inability to (3) Atrial tachycardia,flutter,or fibrillation perform functions as a member due to limitations of (4) Left bundle branch, second-and third-degree atrioven- endurance. tricular block.These blocks will result in disqualification (8) Bronchiectasis with significant residual impairment of unless exercise can be performed with an adequate heart pulmonary function or requiring frequent therapy.Bron- ram response. They can result in frequent episodes of chiectasis can result in the inability to perform functions pain, the inability to perform work,and have the poten- as a member due to limitations of endurance. tial for sudden incapacitation. moo Elton 1582-16 MEDICAL.REQUIREMENTS FOR FIRE FIG LITERS AND INFORMATION FOR FIRE DEI'.U&TMENT IN(Mil LN,S (5) Ventricular tachycardia. Ventricular tachycardia can to limitations of endurance and the inability to perform result in the potential for sudden incapacitation and the job functions due to limitation of balance. inability to perform job functions due to limitations of (7) Aneurysm of the heart or major vessel, congenital or strength or endurance. acquired.An aneurysm of the heart or major vessel can (6) Hypertrophy of the heart Hypertrophy of the heart can result in frequent episodes of pain,the inability to per- result in the potential for sudden incapacitation and the form work,and the potential for sudden incapacitation. inability to perform job functions due to limitations of (9) ,Any other vascular condition that results in a person nut endurance. being able to perform as a member. (7) Recurrent paroxysmal tachycardia. Recurrent paroxys- mal tachycardia can result in the potential for sudden A.3-9.2 Category 8 medical conditions of the abdominal incapacitation and the inability to perfor job function organ and gastrointestinal system include the following: due m limitations afstrength or endurance. (I) Cholecystitis (that which causes frequent pain due to (9) History of congenital abnormality that has been treated stones or infection).Cholecystitis can result in frequent by surgery but with residual complications or that has not episodes of pain or the inability to perform work. been treated by surgery, leaving residuals or complica- (2) Gastritis (that which causes recurrent pain and impair- tioos. A congenital abnormality can result in frequent men[).Gastritis can result in frequent episodes of pain or . _ episodes of pain or inability to perform work and the the inability to perform work potential for sudden incapacitation. (3) GI bleeding can cause fatigue, and ar hemodynamic (9) Chronic pericarditis.endocarditis,or myacarditis.These instability resulting in inability to perform work. conditions can result in the inability to perform job funs (4) Acute hepatitis (until resolution of acute hepatitis as lions due to limitations of endurance, determined by clinical examination and appropriate lab- (10)Cardiac pacemaker. If the person is pacemaker-depen- oratory testing). Acute hepatitis can result in frequent dent.[hen the risk for sudden failure due to trauma is not episodes of pain or the inability to perform work acceptable.Those with cardiac pacemaker can have the (5) Hernia (unrepaired inguinal or abdominal hernia that potential for sudden incapacitation. could obstruct during duty). A hernia can result in the (II)Coronary artery vasospasm.Those with cardiac artery potential for sudden incapacitation. vasospasm can have the potential for sudden incapaci- (6) Inflammatory bowel disease (that which causes disabling talon. pain or diarrhea).Inflammatory bowel disease can result (12)Any other cardiac condition that results in a person not in frequent episodes of pain or the inability to perform being able to perform as a member. work. It is a progressive illness leading to functional A-38.2.2 Category 8 medical conditions of the vascular sys- impairment. tern include the following: (7) Intestinal obstruction (that is, recent obstruction with (I) Hypertension that is uncontrolled,poorly controlled,or impairment).An intestinal obstruction can result in fre- requires medication likely to interfere with the perfor- quern episodes of pain, the inability to perform work, mance of duties.Acceptable hypertension is a blood pres- and the potential for sudden incapacitation. sure less than 180/100 and no target organ damage. (9) Pancreatitis (that is, chronic or recurrent with impair- Hypertension is a progressive illness leading to functional mein). Pancreadris can result in frequent episodes of impairment with the potential for sudden incapacitation. pain or the inability to perform work. (2) Peripheral vascular disease,such as Raynaud's phenome- (9) Resection,bowel (if frequent diarrhea precludes perfor- non,that interferes with performance of duties or makes mance of duty).A bowel resection can result in frequent the individual likely to have significant risk of severe episodes of pain or the inability to perform work. injury. Peripheral vascular disease can result in frequent (10) Ulcer, gastrointestinal (where symptoms are uncon- episodes of pain or the inability to perform work and the trolled by drugs or surgery).A gastrointestinal ulcer can inability to perform functions as a member due to limits- result in frequent episodes of pain or the inability to per- dons of endurance. form work. (3) Recurrent thrombophlebitis. Recurrent thrombophlebi- (II)Cirrhosis,hepatic or biliary(that which is symptomatic or tis can result in frequent episodes of pain or the inability in danger of bleeding). Cirrhosis can result in frequent toperfor work and the inability to perform functions as episodes of pain or the inability to perform work a member due to limitations of endurance. (12)Chronic active hepatitis. Chronic, active hepatitis can (41 Chronic lymphedema due to lymphopathy or severe result in frequent episodes of pain or the inability to per- venous valmlar incompetency.Chronic lymphedema can form work. _. result in the inability to perform functions as a member (13)Any other gastrointestinal condition that results in a per- due to limitations of endurance. son not being able to perform as a member. (5) Congenital or acquired lesions of the aorta ohm major yes- A-S10.l2 Category IImedical conditions of the reproductive sets,forexample.syphilitic aortitis,demonstrable athero- sclerosis that interferes with circulation, and congenital organs inc u g: acquired dilatation of the aorta.Congenital or acquired (1) Pregnancy.Pregnancy can result in frequent episodes of lesions of the aorta or major vessels an result in the pain or the inability to perform work;progressive inabil- potential for sudden incapacitation and the inability to icy to perform work due to limitations of endurance,flex' performjoh functions due to limitations of endurance. ibility, or strength; and the inability to properly wear (6) Marked circulatory instability as indicated by orthostatic protective equipment.(See B-4.4,Renuductive.) hypotension, persistent tachycardia, and severe periph- (2) Dysmenorrhea that leads to recurrent incapacitation. eras vasomotor disturbances.Marked circulatory instabil- Dysmenorrhea can result in frequent episodes of pain or icy can result in the inability to perform job functions due the inability to perform work. 2000 Ethlior APPENDIX is 1582-1; (3) Endametriosis,ovarian cysts,or other gynecologic condi- dislocation, if range of motion u is intact, would not lions (severe. leading to recurrent incapaciutionl. exclude a person. Dislocation of ajoint can result in the Endometriosis,ovarian cysts,and other gynecologic con- inability to perform functions as a member due to limita. ditions can result in frequent episodes of pain or the Lions of strength or flexibility. inability to perform work. (4) Joint reconstruction. ligamentous instability, or joint (4) Testicular or epididymal mass(that which requires medi. replacement. In cases where recurrent or with residual cal evaluation).A testicular or epididymal mass can result limitation of motion of a degree to interfere with success. in frequent episodes of pain or the inability to perform ful and sale performance of fire-fighting duties,surgery work. This is a progressive illness leading to functional for a torn anterior cruciate ligament could disqualify if impairment. quadricep strength is not normal or if the knee is lax or (5) Any other genital condition that results in a person not develops pain or swelling when stressed. These condi. being able to perform as a member dons of the joint can result in the inability to perform A-3-10.2.2 Category B medical conditions of the urinary sus- functions as a member due to limitations of strength or tem include the following flexibility. (3) Chronic osteoarthritis or traumatic arthritis (in cases (1) Diseases of the kidney requiring dialysis. Diseases of the where recurrent exacerbations leads to impairment). kidney can result in frequent episodes of pain or the Chronic osteoarthritis or traumatic arthritis can result in inability to perform work.Kidney disease is a progressive frequent episodes of pain.the inability to perform work. illness leading m functional impairment. and the inability to perform functions as a member due (2) Diseases of the ureter, bladder, or prostate that require to limitations of strength.endurance,or flexibility. frequent or prolonged treatment. These diseases can (6) Inflammatory arthritis(in cases where it is severely recur- result in frequent episodes of pain or the inability to per- rent or a progressive illness or with deformity or limit". form work. don of range of motion of a degree to interfere with (3) Any other urinary condition that results in a person not successful and safe performance of fire-fighting duties). being able to perform as a member. Inflammatory arthritis can result in frequent episodes of A-3-11.2 Category B medical conditions of the spine, scapu- pain, the inability to perform work,and the inability to lae,ribs,and sacroiliac joints include the following: perform functions as a member due to limitations of (1) Arthritis that results in progressive impairment or limita- strength,endurance,or flexibility.don of movement. Arthritis is a progressive illness that (7) Any other extremity condition that results in a person not leads to functional impairment.Arthritis can result in the being able to perform as a member. inability to perform functions as a member due to limits- A-3.13.1 Category A medical conditions of a neurological ---- —dons of endurance or flexibility. nature include the following: (2) Structural abnormality, fracture, or dislocation that is a progressive or recurrent impairment These conditions (a) Ataxias of the heredo-degenerative type.Ataxias of the are progressive illnesses leading to functional impair- heredo-degenerative type can result in the inability to perform ment.These illnesses can result in the inability to per- functions as a member due to limitations of balance. form functions as a member due to limitations of (b) Cerebral arteriosclerosis as evidenced by documented strength or flexibility, episodes of neurological impairment. Cerebral arteriosclero- (3) Nucleus pulposus, herniation of, or history of laminec- sis can result in the inability to perform functions as a member tomy, discectomy, or fusion. These conditions are pro- due to limitations of strength and/or balance. gressive illnesses leading to functional impairment and (c) Progressive multiple sclerosis or multiple sclerosis with the inability to properly wear protective equipment evidence of progression within previous three years.Multiple (4) Ankylosing spandylitis.This condition can result in the sclerosis can result in the inability to perform functions as a inability to perform functions as a member due to limita- member due to limitations of strength or flexibility. eons of endurance or flexibility. (d) Progressive muscular dystrophy or atrophy.This condi- (5) Any other spinal condition that results in a person not don can result in the inability to perform functions as a mem- being able to perform as a member. ber due to limitations of strength and/or balance. A-3.12.2 Category B medical conditions of the extremities (e) Epileptic conditions.After a provoked seizure,with the include the following: precipitant identified and alleviated,with subsequent normal (I) Limitation of motion of ajoint of a degree to interfereCi or FIR[scan,normal EEG,normal neurological exam,free with successful and safe performance of Ere-fighting of recurrence without medication ForoneyencandwithdeEn- duties.The limitation of motion of a joint can result in 'Live statement from a qualified neurological specialist,amem- the inability to perform functions as a member due to ber can be cleared to return to duty. limitation of flexibility. A-3-I3.3 Category B medical conditions of a neurological (2) Amputation or deformity of a joint or limb of a degree to nature include the following: interfere with successful and safe performance of fire- fighting duties.The amputation or deformity of a joint or (a) Congenital malformations(that is,severe vascular mal- limb can result in the inability to perform functions as a formations that interfere with the ability to wear protective member due to limitations of strength and/or balance. equipment). Congenital malformations can result in the (3) Dislocation of ajoint.Recurrent dislocation of ajoint or inability to properly wear protective equipment. dislocation with residual limitation of motion of a degree (b) Migraine (that is. recurrent, with impairment uncon- to interfere with successful and safe performance of fire- trolled). Migraines can result in frequent episodes of pain or lighting duties;successful surgery for recurrent shoulder the inability to perform work. 2.710 Edeon 1582-IS MIEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DE19RT>IENT PIfSICL\NS (c) Clinical disorders with paresis, paralysis,dvscoordina- (0 Any other hematological condition that results in a non,deformity,abnormal motor activity.abnormality ofsensa- person not being able to perform as a member. - don, or complaint of pain (progressive or severe). These disorders are progressive illnesses leading to functional A-3-16.1 Category A medical conditions of endocrine and impairment.They can result in the inability to perform func- metabolic disorders include diabetes mellitus that is treated Lk)ns as a member due to limitations of strength,flexibility.or with insulin or an oral hypoglycemic agent and that includes a balance. history of one or more episodes of incapacitating hvpoglyce- (d) Subarachnoid or intracerebral hemorrhage, verified mia. Diabetes mellitus can result in the potential for sudden either clinically or by laboratory studies.except for those cor- ncapaumn°°' rected with verification by laboratory studies and report of A-346.2 Category B medical conditions of endocrine and ' treating physician. Subarachnoid or intracerebral hemor- metabolic disorders includes the following: rhage is a progressive illness leading to functional impair- ment. This illness can result in the potential for sudden (a) Diseases of the adrenal gland.pituitary gland.parathv- incapacitation. roid gland, or thyroid gland of clinical significance (that is, lei Abnormalities from recent head injury,such as severe symptomatic and poorly controlled).These diseases can result cerebral contusion or concussion. The abnormalities can in frequent episodes of pain, the inability to perform work, result in the potential for sudden incapacitation. and the potential for sudden incapacitation. (D Any other neurological condition that results in a per- (b) Nutritional deficiency disease or metabolic disorder son not being able to perform as a member. (where clinically significant and not correctable by replace- ment therapy or other medication).Nutritional deficiency dis- A-2Lk.2 Category B medical conditions of the skin include ease or metabolic disorder can result in frequent episodes of the following: pain or the inability to perform work. (a) Acne or inflammatory skin disease (if condition pre- (c) Diabetes mellitus requiring treatment with insulin or crudes good fit of protective equipment such as SCBA face oral hypoglycemic agent. Diabetes mellitus can result in epi- piece, or prevents shaving).Acne or inflammatory skin disease sodes of pain or inability to perform work. It is a progressive can result in the inability to properly wear protective equipment. illness leading to functional impairment and can result in the (b) Eczema (if broken skin results in impairment From potential for sudden incapacitation. infections or pain or interferes with seal between skin and per- (d) Any other endocrine or metabolic condition that sonal protective equipment). Eczema can result in frequent results in a person not being able to perform as a member. episodes of pain or the inability to perform work. (c) Any other dermamlogic condition that results in the A-3-17.2 Category B medical conditions of systemic diseases person not being able to perform as a member. and miscellaneous conditions include the following A-3-15.1 Category A medical conditions of blood and blood- (a) Connective tissue disease, such as dermatomyositis, forming organs includes the following: lupus erythematosus,scleroderma, and rheumatoid arthri- tis(where manifested by systemic impairment or limitations (a) Hemorrhagic states requiring replacement therapy of motion).These connective tissue diseases are progressive (for example, von Willebnnd's disease, thrombocytopenia, illnesses leading to functional impairment and the inability hemophilia).These hemorrhagic states can result in frequent to function as a member due to limitations of strength or episodes of pain or the inability to perform work. flexibility.(b) Sickle cell disease (homozygous). Sickle cell disease (b) Residuals from past thermal injury(for example,frost- can result in frequent episodes of pain or the inability to per- bite resulting in significant symptomatic discomfort).Residu- form work and the potential for sudden incapacitation. als from past thermal injury may result in the inability to A-Z-15.2 Category B medical conditions of blood and blood- perform functions as a member due to limitations of strength, forming organs include the following endurance,or flexibility. (a) Anemia (in cases that require regular rransfusions). (c) Documented evidence of a predisposition to heat Anemia can result in frequent episodes of pain or the inability stress with recurrent episodes or resulting residual injury. A to perform work. Anemia is a progressive illness leading topredisposition to heat stress can result in the potential for sud- functional impairment den incapacitation and the inability to perform functions as a (b) Leukopenia (where chronic and indicative of serious member due to limitations of endurance. illness). Leukopenia is a progressive illness leading to tune- (d) Any other systemic condition that results in a person mom impairment. not being able to perform as a member, (c) Polycythemia vera (where severe, requiring treat- A416.2 Category B medical conditions of tumors and malig- men ). Polycythemia vera can result in frequent episodes of nant diseases can include the following pain or the inability to perform work and the potential for sud- den incapacitation. (a) The medical evaluation of any person with malignant (d) Splenomegaly(where the spleen is susceptible to nip- disease that is newly diagnosed,untreated,or currently being ture from blunt trauma). Splenomegaly can result in the treated will be deferred. potential for sudden incapacitation, Any person with treated malignant disease should be evalu- (e) History of thromboembolic disease (that is, m ated based on that persons current physical condition and on than one episode or an underlying condition).A history of the likelihood of that person's disease to recur or progress. thromboembolic disease can result in the potential for sud- (b) Any other tumor or similar condition that results in a den incapacitation. person not being able to perform as a member. 2000 EdNon APPENDIX A 1382-19 A-3.19.2 Category B medical conditions of a psychiatric a. HIV nature include the following: b. Hepatitis B surface Antibo dy dy (HBsAb). if not previ- (a) Any person with a history of a psychiatric condition or ously known to be positive substance abuse problem should be evaluated based on that c. Hepatitis B surface Antigen(HBsAg),if not previously persons current condition. Psychiatric conditions and sub known to be positive HBsdb stance abuse problems can result in frequent episodes of pain d. Hepatitis C Antibody(HCAb) or the inability to perform work and the potential for sudden e. If HIV prophylaxis is to be given, the following tests incapacitation.These conditions are progressive illnesses lead- should be done: ing to functional impairment. I. CBC (b) Any other psychiatric condition that results in a person 2. Glucose,renal and hepatic chemical function not being able to perform as a member. 3. Pregnancy test for females A-3-20.2 Category B medical conditions concerning chemi- (4) Listing of testing to be done on source patient,including call,drugs,and medications include the following the following (a) Anticoagulant agents such as coumadin can be permit- a. HIV ted if the anticoagulared state is controlled such that the pro- b. HBsAg thrombin time or INR has been in the therapeutic range on a c. HCAb stable medical regimen for at least one month and that no (6) If source is available,interview for HIV,HepB,and HepC other coexisting conditions would either contribute to a risk/status. bleeding diathesis or by themselves preclude certification for (6) Determination of risk and need for PEP full duty.Anticoagulant agents can result in frequent episodes (7) Member counseling regarding PEP medication(s) and of pain or the inability to perform work.as well as the potential side effects of treatment.A.printed fact sheet should be for sudden incapacitation. available for the member to review. (b) Cardiovascular agents (for example,antihypertensives) (8) If PEP prophylaxis is to be given, it should be done as an result in frequent episodes of pain or the inability to per- soon as possible after the incident, preferably within 2 form work,as well as the potential for sudden incapacitation. hours. (c) The use of narcotics can result in frequent episodes of (9) Members on prophylaxis need to be followed(preferably pain or the inability to perform work,as well as the potential by an ID specialist) for the duration of their treatment for sudden incapacitation. (10)Assessment of tetanus status and administration of dT (d) The use of sedative-hypnotics can result in frequent booster,if appropriate episodesof pain or the inability to perform work,as well as the (III Assess HepB scams potential for sudden incapacitation, a. If previously immunized with a positive poseimmuni- (c) The use of stimulants can result in frequent episodes zation titer,no further treatment is needed. of pain or the inability to perform work,as well as the potential b. If previously immunized, titer was negative, and for sudden incapacitation. source is HBsAg positive or high risk,give Hepatitis B (f) The use of psychoactive agents can result in frequent Immune Globulin (HB1C)as soon as possible—pref- episodes of pain or the inability to perform work,as well as the enbly within 24 hours—and a dose of Hepatitis B potential for sudden incapacitation. vaccine. (g) The use of steroids can result in frequent episodes of c. If previously immunized and titer is unknown,draw pain or the inability to perform work. titer. (h) Any other chemical,drug,or mediation thatresulu in I. If titer u positive,no further treatment is needed. a person not being able to perform as a member is included 2. If titer is negative and source is HBsAg positive or in this group. high risk,then give Hepatitis B Immune Globulin (HBIC) as soon as possible—preferably within 44-2.1 Physicians who care for members need to be familiar 24 hours—and a dose of Hepatitis B vaccine. and keep up-to-date with the most current recommendations d. If previously immunized with negative titer and revac- for post-exposure prophylaxis (PEP) for bioodbome patho- cinated with a negative titer,give HBIG immediately gen(BBP)exposures.Also there should be a written protocol and a second dose 1 month later. for dealing with members who present with BBP exposures. e. If never immunized,give HBIG and begin Hepatitis B This should be based on the following elements: vaccine series. -3IY Fief sheet that explains in lay language the risks of infec- (12)Follow-up instructions should include the following don, the various prophylactic and therapeutic options. a. Adverse events and side effects of PEP the testing and follow-up that will be needed and recom- mendations for personal behavior (i.e.. safe sex, blood b. Signs and symptoms of retroviral illness(fever,aden- donation,and so forth) following an exposure. opathy,rash) (2) Classification table to determine the exposure type and c. Appointments for follow-up blood work,including the recommendation for prophylaxis.Current recommenda- following-.tions of U.S.Department of Health and Human Services, 1. HIV at 6 weeks,3 months,and 6 months Centers for Disease Control and Prevention,and Public 2. HBsAb and/or HCAb at 6weeks.3 months,and 6 Health Services. months,if source is HepB and/or HepC positive (3) Listing of testing to be done on exposed member,includ- 3. Every other week CBC.renal and liver function,if ing the following: receiving PEP 2000 Ed On 1582 2(1 NIEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORSL\CION FOR FIRE DEPARTMENT PHYSICIANS A4-2.2 Post-exposure prophylaxis may also be indicated for or lung-duration incident. Medical evaluation and treatment the following diseases: in the on-scene rehabilitation area should be conducted •- (q Diphtheria according to emergency medical service (EMS) protocols (2) Hepatitis A developed by the fire department in consultation with the fire (3) Meningitis department physician and the EMS medical director. If (4) Penussi Meningitis advanced life support(AfS) personnel are available,this level (5) Rabies of EMS care is preferred. (6) Varicella Zoster A-5-1.2 Weather factors during emergency incident can A43.1 An annual TB program should include the following: impact severely on the safety and health of members,who are operating during extremes of heat or cold.'Where these Eac- (I) Documentation ofa two-step purified protein derivative tors combine with long-duration incidents or situations that (PPD)prior to this PPD or a 0-mm PPD within the past require heavy exertion.the risks to members increase rapidly. I year. The fire department should develop procedures,in consult- (?) Placement of PPD and reading by a wined,designated don with the fire department physician,to provide relief from reader within 49 hours to 72 hours of placement. Mem- adverse climatic conditions. ben with a history of positive PPD should fill out a ques- The following are typical rehabilitation considerations for uonnaire. operations during hat weather extremes: (3) PPD results should be documented in millimeters (mm). (I) Moving fatigued or unassigned members away from the A test with no skin reaction should be recorded as 0 mm. (4) A PPD skin test will be considered positive if the following hazardous area of the incident conditions are present: (2) Removing personal protective equipment (3) Ensuring that personnel are out of direct sunlight a. Greater than 5 mm in someone who is immunosup- (4) Ensuring that there is adequate air movement over per- pressed - sonnel,either naturally or mechanically b. Greater than 10 mm in someone with a normal (5) Providing members with fluid replenishment,especially immune system who is at risk for conversion due to an water exposure (6) Providing medical evaluation for personnel showing c. Greater than 10 mm increase from previous reading signs or symptoms of heat exhaustion or heat stroke (5) If PPD is positive(conversion),the following steps should The following are typical rehabilitation considerations for be taken: operations during cold weather extremes: a. Fill out questionnaire (1) Moving fatigued or unassigned members away from the - b._9btain chest x-ray hazardous area of the incident c. Evaluate for active disease (2) Providing shelter from wind and temperature extremes d. Evaluate for preventative therapy (3) Providing members with fluid replenishment,especially (6) If active disease is diagnosed, the member has to be water removed from any duty until she/he has been deter- (4) Providing medical evaluation for members showing signs mined to be noninfectious. This will occur when ade. or symptoms of frostbite, hypothermia, or other cold- quate therapy has been instituted, the cough has related injury resolved,and 3 consecutive sputum smear for acid-fast A-5-2 2 The assignment of an ambulance or other support bacillus(AFB)on different days are negative. crew to the rehabilitation function is essential during long- A-4-3.2 In the event of an exposure to TB,the following steps duration or heavy-exertion incident operations.This crew can should be taken: assist with rehabilitation functions as well as be available to (13, Member should receive a PPD within 14 days of expo- Provide immediate basic life support needs for memben. sure.Members with a history of positive PPD should fill Advanced life support (paramedic) level of evaluation and outer TB questionnaire. treatment has to be available quickly,however, toensure the (2) Repeat PPD or questionnaire should be done 6 weeks to proper level of care. 12 weeks after the first The medical staff has to have an assigned medical director. (3) If PPD is positive (conversion) or questionnaire is pow- This can be an on-scene physician such as a fire department five,proceed as per(5) and(6) ofA43.1. physician, a remote physician at a base hospital,or a central medical direction facility. A44 29 C4R 19I0.1030 requires that members be offered Hep- A-5-3.2 For major incidents or escalating incidents, medical athis B immunization at no cost to the member.Members who control can be established by the fire department physician or choose to decline the offer of this immunization are required to medical director at the incident scene. sign a written declination. The declination becomes part of a Burn injury. When a member suffers a burn injury, he or member's confidential health data base as specified in Section she should be evaluated as to the extent of injury.First-degree 8-4 of NFPA 1500,Standard an fiat Department Occupation&Safety burns can be treated on scene,and the member may continue and Health Program.Members are allowed to recant at any time duty.Second-degree burns should be evaluated by a physician and receive offered immunizations. familiar with burns,such as an emergency department physi- A-5-I.I Having a preplanned rehabilitation program that is cian,a member of a burn unit,or a fire department physician. applicable to most incident types is essential for the health and Second-degree burns and higher are conditions that demand safety of members.This program should outline an ongoing that the member be removed from emergency response duty. rehabilitation for simple or short-duration incidents as well as After the burns have healed to the extent that there is minimal a process to transition into the rehabilitation needs of a large risk for entry into the member's body of body fluids and chem- 2000 Edition AITESUI3 a 1582-9_I icals encountered during regular duties,he or she can return inhalation. At the emergency department, the victim should to full duty. have an arterial carboxyhemoglobin determined and should The American Burn Association has criteria for referral to be evaluated for possible cyanide wxieity.Ifcanide poisoning a burn center.They arc second-and third-degree burns with is suspected,treatment with a cyanide antidote kit should be characteristics as follows: initiated. Since inducing methemoglobinemia in a patient (I) Exceeding 20 percent body surface area(BSA) with an elevated carboxyhemoglohin level may further impair (2) Exceeding 10 percent BSA for age under Id or over 50 oxygen delivery.only sodium thiosulfate should be given ini- (3) Any third-degree burn over 5 percent BSA Bally. If treatment with hyperbaric oxygen is started. nitrites (4) Involving hands,feet.face,perineum,genitalia,or major may he used. joints A-5-I.3 Items that can assist in limiting temperature stress in (5) Circumferential involving extremities or chest cold environments include heat,blankets.and protection from (6) Caused by contact with chemicals,electricity,or lightning thewind.For hot weather,items should include adequate shade, (7) Coupled with smoke inhalation injury fans.air-conditioning,and muting systems.Food and hydration (8) Associated with multiple trauma needs include water and oral fluids,food,broth,and fruit.Also, (9) Involving patients with pre-existing significant medical for hydration, a 50/50 mixture of water and an electrolyte illness • replacement drink can be provided.Medical equipment.should Masnelaskeletat Sprains. Strains and sprains are among the include blood pressure curb. stethoscopes. oxygen, cardiac monitors.thermometers.and intravenous fluid and supplies. most common member injuries.When they occur during peri- ods when circulating catecholamines are high.such as on the A-5-L4 The incident commander should consider the cir- fireground, the injured member might underestimate the cumstances of each incident and make suitable provisions for severity of the injury.Under such conditions,he or she might rest and rehabilitation of members operating at the incident continue working and worsen the injury. scene. For example, when members consume air from two Evaluation of these type of injuries on the fireground'can SCBA air cylinders (two-cylinder rule), they should be be difficult.The injury might worsen with time due to swelling, assigned to rehab. muscle spasm,and increased pain perception after the emer- gency call it.over. Any acute injury that leads to swelling or A-5 4.5 The measurement of the pulse rate has been used by results in more than a trivial limitation of motion should prob- some fire departments in assessing members during rehabilita- ably be evaluated by a physician. don.A persistently elevated pulse could be a sign of excessive Smoke Inhalation.Smoke inhalation is fortunately becoming stress on the body due to dehydration,heat stress,exhaustion, less common,due to the use of self-contained breathing appa- or cardiopulmonary disease. The use of a pulse rate has not rams.Amember with smoke inhalation should be treated with been studied in a manner that allows strict medical protocol to be recommended.The pulse rate combined with the remain- 100 percent oxygen and transported to an emergency depart- ment Burns involving greater than 15 percent of body surface der of the clinical evaluation of the member may be used to area,facial burns,singed hair,and airway soot are associated determine if the member can return to operations. with more severe airway burns. Lower airway injury can be associated with carbonaceous sputum,wheezing, rates, rhon- chi, and chest pain. Pulmonary function tests can reveal a Appendix B Information for decrease in Forced expiratory volume in one second (FEW). Fire Department Physicians A chest radiograph may disclose infiltrates or atelectasis. Hypoxemia may be seen on arterial blood gas analysis.A nor- This appendix is not a part of the requirements of this MfPA doc- mal chest radiograph and normal arterial blood gas results do ument but is included for infannauionai purposes only. not,however,rule out ignificant smoke inhalation injury. &I Ocrospatoml Safety and Health Problems for Members. Endotracheal intubation should be performed if there is central nervous system.suidor,hypoxemia(PO'less than 60). &LI General. Fire fighting and emergency response are hypercarbia (PCO2 greater than 50), full-thickness burns of very difficult jobs.People in these jobs perform functions that the face or neck,airway or pulmonary edema,or inability to are physically and psychologically very demanding. These handle secretions. Positive end-expiratory pressure (PEEP) functions are often performed under very difficult conditions, should be used if hypoxemia persists despite intubation and (.See Appendix C.) administration of I00 percent oxygen. Inhaled beta-agonise &L2 Physical Load. Studies have shown that fire-fighting and anticholinergics can be used for bronchospasm.Systemic comcosteroids are not recommended for pneumonitis or pul- o lnctons require working az neao maximal heart rates for pro- monaiyedema. Antibiotics may be needed if sputum gram longed periods of time. Heavy protective equipment (induct- stain and culture with fever and leukocytosis suggest the prey ing respirators) and the heat from the fire contribute to this ence of a bacterial pneumonia physical load. Down Member Certainly the scenario involving the discovery &I.3 Toxic Substances. Members and emergency response of an unconscious member is one that is difficult to manage personnel also are exposed to many toxic substances during given the psychological responses of all involved. Of course, their work. Carbon monoxide is the most common contami- the first priority is the safe removal of the victim from the haz- nanq studies have shown individual exposures that are as high ardous area.Then the Airway, Bleeding.Cardiac (ABCs) are as 5000 ppm during actual fires.Other significant exposures carried out and a secondary survey performed.Transport to a common during fires include cyanide, acrolcin, hydrogen hospital should be expedited. chloride,nitrogen dioxide,and benzene.The burning of plas- Any unconscious member should be treated with 100 per. tics and other synthetic materials can expose members to cent oxygen, since carbon monoxide poisoning is common other toxic materials, such as isocyanates and nitrosamines. and cyanide poisoning possible as secondary effects of smoke Hazardous materials incidents can involve exposures to many 2000 Billion 1582-22 .IEDICLL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMAnoN FOR FIRE OER\RT)IENT PIf51CI.\NS other toxic materials.Although the use of respirators helps to B-"_ Guidance for Medical Evaluations. reduce exposures. mechanical, environmental, and behav- - ionl factors can limit their use during all phases of a tire. &2.1 Preplacement and Baseline Medical Evaluations. The available health data on members are limited. While Preplacemev medical evaluations Risen an individual's the protection for members has improved over the last several health status before assignment to a position.The purpose of years.exposures might be changing due to the introduction of he amoelonuht ascertain him or whether the individual has any health conditionthe prevents to wear her from the more synthetic materials. Given the delay between exposure job. including the ability to wear protective equipment and onset. (that is, latency) of many occupational illnesses, required for the job.The evaluation should also identify any current or past health studies of members might not reflect health problems that could be substantially aggravated by the future health risks. These limitations should be recognized physical demands and working conditions. Baseline medical when reviewing the available studies, information concerning the applicant's health status can then be compared to subsequent evaluation results for the purpose &1.4 Increased Risk of Injury and Disease. Available data of determining whether the individual has any significant indicate that members have increased risk for injuries, pul- health trends that can be occupationally related. monary disease, cardiovascular disease, cancer, and noise- Two apes of information are essential for a medical pre. , induced hearing loss. The increased risk for injuries is placement evaluation of those performing member duties. expected.given the demands and circumstances of this work. First, the physician must understand the working conditions Fatalities and serious injuries from burns or other fire-scene and physical demands of this occupation. Appendix C pro- hazards can occur. vides a list of the environmental factors encountered in fire The risk for respiratory disease occurs due to the respites fighting and emergency response.The physician also should tom damage caused by many of the components of fire smoke regardingrid additional information from the fith department hs specific jobdduties and task lists (if b the fire depart- (forand example, particulate, acrolein, nitrogen oxides, and so ment has conducted a validation study or job analysis) and on.)Acute reductions in pulmonary function and even hypox- should be familiar with the organization of the fire depart- emia are not uncommon after fires, even in asymptomatic man.For the evaluation of some medical conditions,the phi- members.Permanent damage from smoke inhalation has also sician will need to obtain further information about specific been reported. Studies of chronic pulmonary changes from job duties in order to make a determination. This might fire fighting have not had consistent results. Some follow-up require on-site inspections and consultation with fire depart- studies have shown a greater rate of decline in pulmonary ment personnel. function among members over time, while others have not Second,the physician needs to have accurate information been able w detect this change. Increased use of protective about the person's disease or medical condition, the func- equipment and job selection factors(ill members transferring tional limitations associated with that condition, and an to other duties)could account for these inconsistent findings. understanding of how physical demands and working condi- tions strenuous work demands fire fighting combined would impact on that condition.An accurate diagnosis is withTheexposuress carbon mans offe and otherin toxicmsub- often the key factor in determining the person's capability. For example,different skin diseases can have similar clinical stances can increase the risk for cardiovascular disease appeannces but can markedly differ in their response to envi- among members. Acute respiratory changes also can stress ronmental exposures- The physician should also recognize the cardiovascular system-This increased cardiovascular die- that individual variability can exist between persons with the ease risk has been documented even in some mortality stud- same clinical condition. ies. despite the job selection factors that tend to mask any Upon completion of the examination,the physician should increase when compared to the general population_ Other inform the authority havingjurisdic don whether the applicant studies have not detected this risk. Certainly, the combing- is medically qualified to perform as a member. tiori of the physical stress of fire fighting and exposures for a B-2.2 Periodic Medial Evaluations. The periodic medical person with preexisting coronary heart disease would be evaluation is designed to evaluate the person's continued abil- expected to increase the risk of a myocardial infarction or icy to perform his or her duties and to detect any othersignif- o[her acute event.However,the degree of this acute risk and icant changes in the condition of his or her health.The latter whether fire fighting also contributes to the development of includes possible job-related changes or abnormalities. coronary heart disease is uncertain. Every year,each member will be medically evaluated by the Increased cancer risk for members has been found in sty- fire department physician. This Medical evaluation includes e al recent studies.While not totally consistent, these studies an update on the member's medical history,including any sig- generally show an increased risk of brain cancer.(gastrointes- nificant changes,a brief review of symptoms,and a report on final cancers) colon cancer. prostate cancer.lymphoma.and any significant job-related exposures experienced during the leukemia among members in many different parts of the pastyear.Height weight,visual acuity,and blood pressure are world.Increased incidence of other cancer sites has also been measured and recorded.The extent of the medical evaluation shown in some studies.Several studies are currently under way and additional testing will depend on the member's medical to further evaluate this risk condition. A more thorough evaluation,including a medical examina- Noise-induced hearing loss has now been documented in tion,is conducted on a periodic basis.For individuals less than several studies of members. Members might also be at risk 30 years of age, the medical evaluation and examination is from other specific exposures including infectious diseases conducted at least every three years;for those 30 to 39 years of and liver, kidney, or neurological damage from exposure to age,at least every two years; and for those 40 years of age or specific chemicals. over, every year. This evaluation should include an updated 2000 Edition APPENDIX 0 1582-23 medical and interval history.complete physical examination, (11)Audiometry vision testing,audiometry.pulmonary function testing,and a (12)Visual acuity and peripheral vision testing CBC,urinalysis,glucose,BUN.creatinine.liver function tests, (l3)Pulmonary function testing and lipid profile. (14)Laboratory testing,if indicated The use of chest x-rays in surveillance activities in the (15)Diagnostic imaging,if indicated absence of significant exposures,symptoms.or medical find- (Ili)Electrocardiography,if indicated ings has not been shown to reduce respiratory or other health impairment. Therefore, only preplacement chest x-rays are B-2.3.2.1 Laboratory Tests. CBC. biochemical test battery. recommended. urinalysis,glucose. BUN,creaunine,liver function tests,and 4 No firm guidelines For stress electrocardiography in asymp- lipid profile, should be conducted for detecting specific ill- tornado individuals have been developed. There have been nesses as well as developing a baseline for later comparison. problems with false-positive results from this testing,especially H-2.3.2.2 Xmas. A baseline chest x-ray can be helpful for in age groups and in women. In those with one or individuals with a history of respiratory health problems or morere risk k factors focoronary artery disease,there is probably symptoms.For others,it can be useful for later comparison. justification for performing the testing.As well,stress tests are more important in those whose work deals with public safety. B-2.3.2.3 Pulmonary Function Testing. Pulmonary function '1f -- Stress tests can be performed using a treadmill,birycle,or testing can be helpful for individuals with a history of respira- stair climber, as long as the protocol being used gradually tory health problems and as a baseline for later comparison.A increases in workload metabolic equivalent of resting energy baseline test should be administered by an experienced per- expenditure (NETS). A submaximal test,with the endpoint son.Only aspirogram that is technically acceptable and dem- being the attainment of 35 percent of predicted maximal onstrates the best efforts by an individual should be used to heart rate (PMHR), may be performed.Additional informa- calculate the forced vital capacity(PVC)and forced expiratory don gained by performing a maximal symptomdimited test volume in one second(FEVI). might not be worth the additional time,effort,cost.and risk. A reasonable approach is to start periodic treadmill testing B-2.3.2.4 Audiometry. Audiograms should be performed in on members at age 40. In those with one or more coronary an ANSI-approved soundproof booth (ANSI 53.1, Maximum artery disease risk factors (premature family history(less than Permissible Ambient Noise Levels for Audiometric Test Roams) with age 55), hypertension, diabetes mellitus, cigarette smoking, equipment calibrated to ANSI standards (ANSI S3.6,Specifica- tion hypercholesterolemia(total cholesterol greater than 240 tun for Audionecen). If a booth is unavailable, the test room or HDL cholesterol less than 35)],testing should be started by sound pressure levels should not exceed those specified in the age 35.The frequency of testing should increase with age,but federal OSHA noise regulations(29 CFR 1910.95). at the minimum the test should be done at least every two B-2.3.2.5 Electrocardiography. Baseline electrocardiography years. Testing can also be done as indicated for those with should be conducted. (Periodic resting electrocardiograms symptoms suggestive of coronary artery disease,as reported in have not been shown to be useful,but may be reasonable as a their yearly medical histories or interim reports. member's age increases.) Conversely,it is known that even maximal stress testing fre- quendy misses cardiac abnormalities seen during actual fire- B-2.4 Reporting the Results of the Medical Evaluation. All ' fighting duties. E individuals participating in a medical evaluation should be B-P.3 Content of the Medical Evaluation. informed ahead of time about the purpose of the medical evaluation and the content of the exam.The results of any B-2.3.1 Medical and Occupational History. The medical his- medical evaluation are considered to be confidential medi- tory should cover the person's known health problems,such cal information,subject to customary patient-physician con- as major illnesses,surgeries,medication use,allergies,and so fidentiality restrictions. Under most circumstances, results forth. Symptom review is also important for detecting early and recommendations arising From the evaluation should be signs of illness. In addition,a comprehensive medical history expressed in general terms without specific diagnostic infor- should include a personal health history,a family health his- matron. In cases where more specific information is needed tory, a health habit history, an immunization history, and a in order to make a decision on the status of a candidate or reproductive history.An occupational history should also be member,a specific consent form releasing that information obtained to collect information about the person's past occu- should be obtained from the candidate or member.Blanket pational and environmental exposures. or general -release of medical information' forms should not be used. 8.2.3.2 Medical Examination. The medical examination In most cases,a simple statement like one of the following includes the following organ systems and tests: will suffice: (I) Vital signs, such as pulse, respiration, blood pressure, (a) Based on the results of the preplacement medical eval- and.if indicated.temperature uation of December 10, 1996,Jane Doe is (or is NOT) medi- (2) Dermatological tally certified to engage in training and emergency operations (3) Ears,eyes,nose,mouth,throat for Anytown fire Department. (4) Cardiovascular (b) Based on the results of the preplacement medical eval- (5) Respiratory nation of December 10,1996,John Doe is NOT medically cer- (6) Gastrointestinal titled to engage in training and emergency operations for (7) Genitourinary Anytown Fire Department.He has been advised of the medical (8) Endocrine and metabolic reasons for this recommendation and of the policies and pro- (9) Musculoskeletal cedures available to him if he disagrees with the results of the (10) Neurological medical evaluation. 2000 Edition 1522 24 SICDIGkL REQUIREMENTS FOR FIRE FIGHTERS 'IND INFORMATION FOR FIRE DEPARTMENT PI I`SICIANS B-2.5 Second Opinions. Fire department policies and proce- Administration(14 CFR67.13161995) dues not grant medical dures should allow for a medical second opinion when a candi- certificates to diabetics treated with insulin and severely limits date or member disagrees with the results or recommendations those on oral hypoglycemic agents. of a medical examination conducted by the fire department B-7 2 Asthma and Reactive Airways Disease. The diagnosis physician or when the fire department physician is uncertain of asthma and related airway hyperactivity disorders is often about the limitations or prognosis of the individual'scondition. confounded by definitional issues. For the purposes of Often other physicians will not be familiar with the duties and demands of fire fighting and emergency response.When possi- member followingc criterian. a variety of airway disorders that ble, the fire department physician should help educate the meet the mt can be included. Asthma is a other physician about how the individually condition could b e individuals,nlc inflammatory disorder of the airways. In suscepti- affectorbeaffectedbyfirefighting.If there is still disagreement We this with widesprtionead causes symptoms that are about the condition or placement recommendation, a third usually associated with widespread but variable airflow physician(acceptable toboth the fire department and the can- obstruction that is often reversible,either spontaneously or didate)can be consulted with treatment,and causes an associated increase in airway responsiveness to a variety of stimuli. B-2.6 5fusculoskeletal System. Some of die injuries or prob- Since asthma is a highly prevalent disease, a number of lems encountered in this system will need functional capacity member applicants will require special evaluation. Combus- evaluation to determine fitness for duty, Physical therapy pro- don products,exercise,and cold air are all potent provokers Men often design tests for employers to determine ability to of an asthma attack.Some of these exposures are unavoidable, perform tasks similar to those required as part of their essen- even with SCBA use. If a candidate has a diagnosis or symp- tialjob functions.These tests should be based on direct mea- toms consistent with an asthma-like disease, many factors will surements of the actual job functions. These functional need to be considered.An asthma attack during a suppression capacity evaluations can be especially useful when a member activity could harm the member, his fellow members, or a has been cleared for full duty by a physician who is not familiar member of the public. with the essential job functions of a member. The following factors can be used to help in certification: 13-3 Specific Medici Conditions. (1) Persistence of airway obstruction between attacks (as ry) B-3.1 Diabetes Mellinu. The major concern for diabetic measureded fbrequency quency of members is the risk of becominghypoglycemic fire- (2) (frequentNreq and frdi steroid and bronchodilator persistent am use during bronchodilator rue suggests airway ground operationsliandor other oglyce emergency responses..Both iated hyperactivity) enous insulin and oral hypoglycemic agents can be associated (3) Usual type of triggers in the applicant (allergic, infec- with episodes of hypoglycemia that can rapidly progress from tious,exercise-induced,etc.) impaired-judgment to unconsciousness. The most reliable (4) History of hospitalization, emergency room, or urgent predictor of hypoglycemia is a history of it. In one study of insulin-dependent adolescents conducted at the joslin Clinic treatment (Bhatia and Wolfsdorf 1991), all 196 patients experienced (5) Length of time between attacks hypoglycemia at least once during the two-year observation (6) Nocturnal symptoms and other estimates of airway insm- period.Of these,15 percent were classified as severe,based on bdmry loss of consciousness,seizure,or the clinical need for them. Moderate asthma or worse could disqualify an individual peude glucagon or intravenous glucose. It was particularly for member duties.Unknown factors such as the suppression concerning that 24 percent of hypoglycemic episodes of airway hyperactivity with anti-inflammatory medications to detected by blood glucose monitoring were inapparent to the reduce the possibility of a sudden or severe attack are under patients.The probable causes of hypoglycemia were identified investigation and could modify current suggestions. in 71 percent of cases.and the most common were strenuous B3.3 Heart Disease. The medical conditions relating to the exercise and skipped meals or snacks. Both of these precipi- cardiovascular system have been reviewed since the previous tans are likely to occur in emergency responders, especially edition (1997) of this document. The task forces at the fire service personnel.In addition to accelerating glucose uti- lization, strenuous exercise increases insulin sensitivity Bethesda Conference published recommendations for aN- (Wasserman and Sinman 1994). With the tighter glycemic teats competing with cardiovascular diseasein thefoum of the control that is now known to decrease and delay onset of dia Amenran College of Cardiology, in October 1994. The analysis belie complications,there is a concomitantly increased likdi, Fire-fighting activities have a red by the task force has relevance to the evaluation ofineat- hood of exercise-induced hypoglycemia (Wasserman and tiers with cardiovascular disease.Fir Sinman 1994). high static component (i.e., inducing predominantly an Insulin is clearly associated with a much higher risk of increase in blood pressure) and a moderate to high dynamic symptomatic hypoglycemia than are oral agents. In the component(i.e.,inducing predominantly an increase in heart absence of a history of incapacitating hypoglycemic episodes, rate).building,with a similar set of mmendademands include wrestling, and with close medical monitoring,there is probably no rea- body and boxing. Recommendations made by the son to exclude members who are taking oral hypoglycemic task force with respect to athletic activities that have these agents, as long as they have stable weights, diets, and renal physical demands(high static,moderate dynamic) have been function.Although the Americans with Disabilities Act(Public followed in this document. Law 101-336 1990) does not appear to require each diabetic B-3.4 Reproductive. Exposures in the fire-fighting environ- patient to be evaluated for fitness for duty individually,there ment can cause adverse reproductive effects for both males is some case law that disallowed blanket exclusion of insulin- and females.Medical evidence exists to indicate that chemical dependent diabetics from public safety positions (Fire Sc exposure,heat,noise,and physical exertion can affect various Police Personnel Reporter 1994). The Federal Aviation endpoints of reproductive health including fertility,fetal loss. 2000 Edition APPENDIX B 1532 15 and growth parameten of the offspring. All candidates and reactive seizure that can be attributed to a reversible,underly- members should be educated about these risks and about the ing precipitant.These circumstances do not ucccsvrily repre- need to take appropriate steps to limit their exposures. sent an ongoing risk of sudden.unpredictable incapacitation of Also, there could be some situations where a male or a member.Ifa member lens a single seizure.a clear precipitant female ember is attempting to conceive a child and is having not associated with central nervous system damage is identified difficulty.In these situations,where a complete medical evabi- and eliminated,and the individual has no recurrence over the ation has not identified another cense for this infertility, tam- ensuing year.then he or she is probably nut more likely to have porary assignment on a voluntary basis to alternative duty ore. another seizure than the rest of the general population (Spen leave of absence should be considered. cer 1095).Mast lire department physicians will want a qualified Medical evidence exists that certain toxic substances or con- neurologist to verify that an individual with a hlsmty of seizures ditions that are present In the fire-fighting environment are does not,in tact.have epilepsy. dangerous to the safety-and well-being of the fetus.Therefore. Epilepsy is diagnosed by the presence of -unprovoked, it is important to educate all members about these risks and din recurrent seizures—paroxysmal disorders of the central nee-. reasons for recommending that pregnant members restrict vous system characterized by an abnormal cerebral neuronal their fire-suppression activities.For example.there is good eh- discharge with or without loss of consciousness (Cassino deuce that the fetus is especially sensitive to carbon monoxide. 1994).Treatment of patients with epilepsy is only variably suc- a known significant component of fire smoke. Although the cessful.with roughly 40 percent of patients attaining remission on anti-comulsant therapyc (Hauser and HesdortTer 1990; use of SCBA is used throughouth to be protective,suppression sometimes such equipment is not usedtat. a fire ch equips or haz- Spencer rer recurrence of s seizure activity is defined as five years without ardous materialsr incident. The use eofx such equipment also bakI99) of rthe rc complicating the fitness-for-duty Hauser, and u is s cerns fetaloteethseevolvors,ing such physis cal r and heat.Other thekct that Further achieve issue resi n ing.concernsarel ng, aid g es to temperature work. xtrem stand- the so ct ha onlyx percent eetoc patients who chit slug ing,heavy lifting.and exposures to remp<rawre extremes and do so without toxic side effects of the and-convulsant drug humidity have been related to an increase of preterrn and low (Cassino 1994). birth weight infants. Because the fetus should be protected Partial, simple epilepsy, or recurrent seizures that do not from these exposures at the earliest possible time,the member impair consciousness,are felt to be a disqualifying condition who might be pregnant should obtain early pregnancy testing. because of the uncertainty regarding how much of the brain Recognizing potential risks to the fetus from the firefighting might be involved, and the risk of propagation to other environment is a relatively recent event, and many members regions of the brain, particularly in the highly epileptogenic might not be aware of these risks, environment of the['reground(Spencer 1995). Based on a recent U.S.Supreme Court decision (Interne- This standard is somewhat more liberal than that promul- _ tonal Union et al.v.Johnson Controls.Inc..59L'.S.L W.4209 gated by the Federal Aviation Administration of the U.S. March 20, 1991),the ability to perform as a member is to be Department of Transportation for aircraft pilots (14 CFR the basis for the medical certification without consideration of 67.1316 1995).All epileptics,regardless of therapeutic success health risks to the fetus. However, the pregnant member are denied Ant-, second-, or third-class medical certificates, should be counseled on the potential risks to her fetus due to except under the provisions off}CFR 67.19."Special Issue of her exposures during fire-fighting duties. Medical Certificates." My member who becomes pregnant should be offered the B4 References. opportunity at any time during the pregnancy to be voluntar. Mnegers,J. F., W. A. Hauser, and L R. Elveback. 1979. ily removed from fire-fighting duties and from other dudes "Remission of Seizures and Relapse in Patients with Epilepsy," involving the hazards or physical stress that might endanger £pilepsia 20:729. the fetus.If practical,the member should be offered voluntary Bhatia,V.,an di.I.Wolfsdorf. 1991."Severe Hypoglycemia reassignment to an alternative position. At such time as the in Youth with Insulin-Dependent Diabetes Mellitus: Fre- pregnant member can no longer be medically certified as quency and Causative Factors."Pediatrics,88:1197. being capable of performing fire-fighting dudes,the member Bwnacini,Alan.&reground Command.National Fire Protec- should be reassigned to other duties.At such time as the mem- don Association, 1985. ber is no longer pregnant,the member should be reinstated Cassino, G. D. 1994. Epilepsy: Contemporary Perspectives on to the position held prior to being pregnant. Nursing mem- Evaluation and Motown',Mayo Clinic Proceedings 69:1199. bers should also be advised about the potential exposures to "Emergency Incident Rehabilitation," United States Fire their infants. Administration (FA#I 12). can pose Fire f�Polia Psmrmrzr!Reporter„November 1994,p. 169. B-3.5 Noise-Induced Hearing Loss. This category -diff�culees because a high percentage of current members Hauser.W.A..and D. C. Hesdortfer. 1990. 'Epilepsy Fre- - as quen y,Causes and Consequences."New York: Demos. have noise-induced hearing loss due to their exposures members.Implementation of hearing conservation programs National Fire Incident Reporting System (NFIRS) data • and programs to reduce noise exposures should lead to a base. decrease in the prevalence of this condition in the future. NFP.A 15o_h Standard far Fite Department Safety OfficesI99] edition. B-3.6 Seizures and Epilepsy. It is important to distinguish Public Law 101-336. 1990,Tide I-Employment. between a history of seizures and epilepsy.As much as 10 per- Spencer, S., Personal Communication, 1995. (Spencer is cent of the population will experience at least one seizure in a professor of neurology and director of the Clinical Epilepsy Lifetime,whereas less than I percent of the population qualifies and Electrophvsiologic Monitoring Services at Yale University for a diagnosis of epilepsy(Hauser and Hesdorffer 1990).Many School of Medicine.) conditions producing seizures in the pediatric age group are Title 14, Code for Federal Regulations. Part 1910.1000, Sub known to remit prior to adulthood,and many adults sustain a parts 13-16."Air Contaminants." 2000 Edition 1582--36 MEDICAL REQI IREMENTS FOR FIRE FIGHTERS.AND INFORMATION FOR FIRE DEPARTMENT PHYSICIANS 'Toxic smoke inhalation: Cyanide poisoning in fire vie- Appendix D Guide for Fire Department Administrators • tins."Jones.J. et al.. American Journal of Emergenry Medicine 3:31 7. 1987. Thu appendix is not a part of the sequin-inert of this AFPA deny Wasserman.D.H.,and B.Sinman. 1991.'Exercise in Indi- ummt but is included for informational purposes only. viduals with IDDM."Diabetic Care, 17:924. D-I Legal Considerations in Applying the Standard. The can- sidendan of an application or continued employment of a mem. Appendix C Essential Structural Fire-Fighting bey based on medical or physical performance evluadons involver Functions a deterninadon that is not without legal implications.To this end. This appendix is not a part fthe rnryirements of this,VFPA dot- prior to making an adverse employment decision hosed on the wnens bnt is included Jor informational purposes only. foregoing standard the authority with jurisdicdon might wish to consult with counsel. C-I The medical requirements in this standard were based on D-1.I Individuals with HandicapsDisabilities. The Reha- functonsThese essential functions h consideration of ere what members structural fire-fighting bilitadon Act of 1973,as amended, 29 U.S.C. 791 et seq..and pected to perform at emergency incidents and are derived implementing regulations, prohibit discrimination against from the performance objectives stated in NFPA 1001. Stan- those with handicaps or disabilities under any program rneiv- toga financial assistance from the federal government The • dard for Fire Fighter Professional Qualifications Essential functions are performed in and affected by the Americans with Disabilities Act of 1990,42 U.S.C. § I210f.et follow rag environmental factors: seq.,also prohibits employment discrimination by certain pri- sate employers against individuals with disabilities.In addition, (1) Operating both as a member of a team and indepen- many states have enacted legislation prohibiting discrimination dendv at incidents of uncertain duration against those with handicaps or disabilities.These laws prevent (2) Spending extensive time outside exposed to the elements the exclusion,denial of benefit,refusal to hire or promote,or (3) Tolerating extreme fluctuations in temperature while per- other discriminatory conduct against an individual based on a forming duties:fire fighters are required to perform phvs- handicap or disability,where the individual involved can.with ially demanding work in hot(up to 400°F),humid(up to or without reasonable accommodation, perform the essential 100 percent) atmospheres while wearing equipment that functions of the job without creating undue hardship on the significantly impairs body-cooling mechanisms. employer or program involved. Application of this standard (4) Experiencing frequent transition from hot to cold and should be undertaken with these issues in mind. from humid to dry atmospheres The medical requirements of the 1997 edition of this scan- (5) Working in wet,icy,or muddy areas dard were initially developed and found to be jab-related by a (6) Performing a variety of tasks on slippery, hazardous sur- subcommittee comprised of medical doctors, physiological faces such as on rooftops or from ladders specialists,and Ere service professionals,as processed through ' (7) Working in areas where sustaining traumatic or thermal the NFPA consensus standards-making system. Changes for injuries is possible the current edition have been proposed by a task group com- (8) Facing exposure to carcinogenic dusts such as asbestos, prised of similar expertise. The standard provides, to the toxic substances such as hydrogen cyanide,acids,carbon extent feasible,that decisions concerning candidates and cur. monoxide,or organic solvents,either through inhalation rent members with medical ailments,handicaps,or disabilities or skin contact be made after case-by-case medical evaluations. Thus, most (9) Facing exposure to infectious agents such as Hepatitis B medical conditions have been assigned to Category B. or HIV The medical requirements in this edition of the standard (10)Wearing personal protective equipment that weighs were revised based on the essential functions contained in approximately 50 lb while performing fire-fighting tasks Appendix C.It is recognized that some fire-fighting functions (II) Performing physically demanding work while wearing pos- and tasks can vary from location to location due to differences itive-pressure breathing equipment with 1.5 in. of water in department size,functional and organizational differences, column resistance to exhalation at a flow of 40 L/min geography, level of urbanization, equipment utilized, and (12)Performing complex tasks during life-threatening other factors.Therefore.it is the responsibility of each individ- emergencies sal fire department to document, through job analysis, that (13)Working for long periods of time, requiring sustained the essential functions performed in the local jurisdicdon are physical activity and intense concentration substantially similar to those contained in Appendix C. - (14) Facing life-or-death decisions during emergency conditions There are a wide variety ofjob apalytic techniques available (15) Being exposed to grotesque sights and smells associated to document the essential functions of the job of a member. ---with major trauma and burn victims However, at a minimum, any method utilized should be cur- (16) Making rapid transitions from rest to near-maximal exer- rent,in writing,and meet the provisions of the Americans with don without warm-up periods Disabilities Act[29 CFR 1630.2(n)(3)1.Job descriptions should (17) Operating in environments of high noise, poor visibility, focus on critical and important work behaviors and specific limited mobility,at heights;and in enclosed or confined tasks and functions.The frequency and/or duration of task per- spaces formance,and the consequences of failure to perform the cask (18) Using manual and power tools in the performance of dudes should be specified The working conditions and environmen. (19)Relying on senses of sight, hearing,smell,and touch to cal hazards in which the work is performed should be described. help determine the nature of the emergency,to maintain The job description should be made available to the fire personal safety, and to make critical decisions in a con- service physician for use during the preplacement medical fused, chaotic, and potentially life-threatening environ- examination for the individual determination of the medical mere throughout the duration of the operation suitability of applicants for member. 2000 Edition APPENDIX D 1582-27 D-1 2 And-D scriminadon Laws. Finally. users of this stan- Therefore, physicians with specialties other than occupa- dard should be aware that,while courts are likely to give con- tional need to be considered,as well as the physician's back- siderable weight to the existence of a nationally recognized ground and experience.Knowledge of occupational medicine standard such as NFPA 1582.Sandard on Medical Requirements and experience with occupational health programs.obviously. far Fire Fighters and Information for Fen Depar nent Physicians would be helpful. (e.g., Miller a Sioux Gateway Fire Department. 497 N.W.2d 838 The physician has to be committed to meeting the require- (1993)1,reliance on the standard alone could be insufficient ments of the program.including appropriate record keeping. to withstand a challenge under the anti-discrimination laws. His or her willingness to work with the department to contin- Even in the case of Category A medical conditions,courts can wally improve the program is also importune Finally,his or her still require additional expert evidence concerning an individ- concern and interest in the program and in the individuals in ual candidates or member's inability to perform the essential the department is vital. functions of the job.Until the courts provide further guidance in this developing area of law, some uncertainty as to the There are many options for obtaining physician services, degree and nature of the evidence required to establish corn- (a) Physicians could be paid on a service basis or through pelance with the anti-discrimination laws will remain. a contractual arrangement. Do1.3 Individuals Who Are Members of Protected Classes (b) For volunteer departments,local physicians could be (Race,Sex,Color,Religion,or National Origin). Tide VII of willing to volunteer their services for the program.with addi- the Civil Rights Act of 1964,as amended.42 U.S.C.2000e,and tional member arrangements for payment of laboratory rest- implementing regulations by the Equal Employment Opportu- ing,x-rays.and so forth. nity Commission (EEOC) prohibit discrimination in employ- (c) Some departments could utilize a local health care menton the basis of race,sex,color,religion.or national origin facility for medical care.However,in that case,the department (i.e., protected classes). Under Title VII, an 'employer" is should be sure to have one individual physician responsible defined,generally,to mean a person with"15 or more employ- for the program,record keeping,and so forth. ees for each working day in each of 20 or more calendar weeks in the current or preceding calendar year" (42 U.S.C.2000e) (d) In some cases,it could be possible to have the medical Several federal jurisdictions have held that unpaid volunteer examination by the fire department physician,while some of are not considered to be"employees'under Tide VII. the associated costs could be defrayed by the member's own health insurance.For example,the health insurance provider Additionally, many stares, cities, and localities have could allow the member to have a yearly physical, normally adopted similar legislation. Generally, physical performance performed by the member's personal physician. The health or other requirements that result in"adverse impact"on mem. care insurance provider could allow that physical to be per- -hers 'a protected class (e.g.. on the basis of gender) are formed by the fire department physician with some degree of required to be validated through a study in accordance with reimbursement. EEOC guidelines,if such requirements are to be relied on in making employment decisions. Under EEOC guidelines, a D-3 Coordinating the Medial Evaluation Program. An indi- study validating employment standards in one jurisdiction can vidual from within the deparunent should be assigned the be transportable to another jurisdiction (and therefore used responsibility for managing the health and fitness program. in lieu of conducting a separate study).However,specific pre- including the coordination and scheduling of evaluations and conditions must he met in this regard,and the authority hay- examinations.This person should also act as liaison between ing jurisdiction should seek the advice of counsel before the department and the physician to make sure that each has relying on a transported validation study. the information necessary for decisions about placement, scheduling appointments,and so forth. D-I.4 Pregnancy and Reproductive. Federal regulations, as Confidentiality of all medical data is critical to the success well as many court decisions, including the U.S. Supreme of the program.Members need to feel assured that the infor- Couri s decision in International Union,a at u.Johnson Controls, oration provided to the physician will not be inappropriately Inc. (499 U.S. 187, 111 S.CQ. 1196 (1991U. have interpreted shared. No fire department supervisor or manager should the requirements of Title VII with respect to pregnancy and have access to medical records without the express written reproduction.The authority having jurisdiction should seek consent of the member.There are occasions,however,when the advice of counsel in resolving specific questions concern- specific medical information is needed to make a decision ing these requirements as well as other requirements that can about placement, return to work, and so forth, and a fire be imposed by state or local laws. department manager must have more medical information for decision making.In that situation,written medical consent D-2 Choosing a Fire Department Physician. Several factors should be obtained from the individual to release the specific should be considered in choosing a fire department physician. information necessary for that decision. There are relatively few physicians with formal residency train- Budgetary constraints can affect the medical program. ing and certification in occupational medicine.The fire depart- Therefore,it is important that components of the program be ment physician needs to be qualified to provide professional prioritized such that essential elements are not lost With addi- expertise in the areas of occupational safety and health as these Liana' funding, other programs or testing can be added to areas relate to emergency services.For the purpose of conduct- enhance the program. ing medical evaluations,the fire department physician needs to understand the physiological and psychological demands D-4 Table D4 represents a comparison between NFPA 1582 placed on members and needs to understand the environmen- and OSHA 29 CFR 1910.134. sal conditions under which members have to perform. 2000 Ettan 15S2 28 >IEDIGLLREQUIRE>IENTS FOR FIRE FIGIITERS ANO lNFORSIATtON FOR FIRE DEPARTMENT PH1SICIANS Table 13.4 Comparison of OSHA 29 an,Parts 1910.134,"Medical Requirements"and NFPA 1582.Standard on Medical Regnimnents for Fire Fighters and Information fir Fare Department Phyn'ciane,2000 Edition NFPA 1582 OSHA 1910.134 2-1 Medical Evaluation Process. The employer must establish and implement those elements of the written respiratory pro- 2-1.11 The fire department shall establish and implement a medical evalua- tection program necessary to ensure that any don process for candidates and current members. employee using a respirator voluntanlv is med. icafly able to use that respirator:and that the respirator is cleaned,stored.and maintained so that its use does not present a hazard to the user. Exception:Employers are not required to include in a written respiratory protection pro- gram those employees whose only use of respi- rators involves the voluntary use of filtering face pieces(dust masks). Appendix D-3 Coordinating the Medical Evaluation Program.An individual (3)The employer shall designate a program from within the department should be assigned the responsibility for man- administrator who is qualified by appropriate aging the health and fitness program,including the coordination and training or experience that is commensurate scheduling of evaluations and examinations.This person should also act as with the complexity of the program to admin- liaison between the department and the physician to make sure that each ister or oversee the respiratory protection pro- has the information necessary for decisions about placement.scheduling gram and conduct the required evaluations of appointments,and so forth. the program effectiveness. Confidentiality of all medical data is critical to the success of the program. Members must feel assured that the information provided to the physician will not be inappropriately shared.No fire department supervisor or man- agershmtld have access to medical records without the express written con • - sent of the member.There are occasions when specific medical information is needed to make a decision about placement,return to work,and so forth, and a fire department manager must have more medical information.In that situation,written medical consent should be obtained from the individ- ual to release the specific information necessary for that decision. Budgetary constraints can affect the medical program.Therefore,it is important that components of the program be prioritized such that essen- tial elements are not lost.With additional funding,other programs or test- ing can be added to enhance the program. 2-1.2 The medical evaluation process shall include preplacement medical (1)General,The employer shall provide a evaluations.periodic medical evaluations,and return-to-duty medical evalu- medical evaluation to determine the ations. employee's ability to use a respirator,before the employee is fit rested or required to use the respirator in the workplace.The employer may discontinue an employee's medical evalu- ations when the employee is no longer required to use a respirator. (Shed I of 3) 2000 Edilion APPENDIX D 1582-29 Table D-4 Comparison of OSHA 29 CFR,Parts 1910.134,"Medical Requirements"and NFPA 1582,Standard on Medical Requirements/Fire Fighters and Information for Fire Department Physicians,2000 Edition (Continued) NFPA 1582 OSHA 1910.134 2-1.9 The fire deparment shall ensure that the medical evaluation process (3) Follow-up medical examination. and all medical evaluations meet all of the requirements of Section 2-I. (i)The employer shall ensure that a follow-up medical examination is provided for an employee who gives a positive response to any question among questions I through 8 in Sec- tion 2.Part A of Appendix C or whose initial medical examination demonstrates the need for follow-up medical examinations. (ii)The follow-up medical examination shall include any medical tests,consultations,or diagnostic procedures that the physician or licensed health care professional 1 PLHCP) deems necessary to make a final deternina. don. 2.1.4 Each candidate or current fire fighter shall cooperate,participate,and (7)Additional medical evaluations.At a mini- comply with the medical evaluation process and shall provide complete and mum,the employer shall provide additional accurate information to the fire department physician. medical evaluations that comply with the requirements of this section if: 2-L5'Each candidate or current fire fighter shall,on a timely basis,report to the fire department physician any exposure or medical condition that (i)An employee reports medical signs or could interfere with the ability of the individual to perform as a fire fighter. symptoms that are related to ability to use a respirator; 24.1.1 The components of the annual medical evaluation specified in 24.1.2 of this section shall be permitted to be performed by qualified per- (ii)A PLHCP,supervisor,or the respirator pro- sonnet as authorized by the fire department physician.When other quail- grain administrator informs the employer that fled personnel are used,the fire department physician shall review the data an employee needs to be re-evaluated; gathered during the evaluation. (iii)Information from the respiratory protec- don program,including observations made during fit testing and program evaluation, indicates a need for employee re-evaluation; or (iv)A change occur in workplace conditions (e.g.,physical work effort,protective clothing, temperature) that may result in a substantial increase in the physiological burden placed on an employee. (Shen 2 of 5) 21X0 Edition 1582-30 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PHYSICIANS Table D-t Comparison of OSHA 29 CFR,Parts 1910.134,"Medical Requirements"and NFPA 1582,Standard on Medical Reg sirenrmtr for Fire Fighters and information for Far Department Physicians,2000 Edition (Continued) NFPA 1582 OSHA 1910.13E 2-2 Fire Department Roles. (2) Medical evaluation procedures. 2.2.1 The fire department shall have an officially designated physician who (i)The employer shall identify a physician or shall be responsible for guiding,directing,and advising the members with other licensed health care professional regard to their health,fitness,and suitability for duty as required by NFPAor(PLHCP) to perform medical questionnaire 1500,Standard on Fin.Depanmens Occupational Safety and Health Program the sn initial n ormmedi Lion acal s the edi that obtains the same information a the medical question- naire. 2-2.2 The fire department physician shall be a licensed doctor of medicine or osteopathy. (ii)The medical evaluation shall obtain the information requested by the questionnaire in D-2 Choosing a Fire Department Physician.Several actors should be consid-Sections l and 2,Part A of Appendix C of this ered in choosing a fire department physician.There are relatively few physi- section. clans with formal residency training and certification in occupational medicine.The fire department physician shall be qualified to provide pro- fessional expertise in the areas of occupational safety and health as they relate to emergency services.For the purpose of conducting medical evalua- tions,the fire department physician shall understand the physiological and psychological demands placed on fire fighters and shall understand the environmental conditions under which fire fighters must perform. Therefore.physicians with other specialties need to be considered.The background and experience of the physician should be considered.Knowl- edge of occupational medicine and experience with occupational health programs obviously would be helpful The-physician must be committed to meeting the requirements of the pro- gram including appropriate record keeping.His/her willingness to work (, with the department to continually improve the program is also important Finally,his/her concern and interest in the program and in the individuals in the department is vital. • There are many options for obtaining physician services.They could be paid on a service basis or through a contractual arrangement.For volunteer departments,local physicians might be willing to volunteer their services for the program with additional arrangements to pay for laboratory testing,x- rays,and so forth.Some departments might want to utilize a local health care facility for their care.However,in that case,the department should be sure to have one individual physician responsible for the program,record keeping,and so forth.In some cases it could be possible to have the medical examination by the fire department physician,while some of the associated costs could be defrayed by the fire fighter's own health insurance.For exam- ple,the health insurance provider might allow the fire fighter to have a yearly physical,normally performed by the fire fighter's personal physician. • The health care insurance provider can allow that physical to be performed by the fire department physician with some degree of reimbursement. (Shea l of5) M00 Edson APPENDIX D 15E2-31 Table D-4 Comparison of OSHA 29 CFR,Parts 1910.134,"Medical Requirements"and NFPA 1582,Standen(on Medical Requirement,for Fite Fighters and fnfonnation for Fire Department Physicians,2000 Edition (Continued) NFPA 1582 OSHA 1910.134 2-2.34 For the purpose of conducting medical evaluations,the fire depart- (e) Medical evaluation.Using a respirator may ment physician shall understand the physiological and psychological place a physiological burden on employees demands placed on members and shall understand the environmental con- that vanes with the type of respirator wom,the ditions under which members must perform.The fire department shall pro.job and the workplace conditions in which the vide the fire department physician with a currentjob description for all fire respirator is used,and the medical status of departmentpositions and ranks. the employee.Accordingly,this paragraph P specifies the minimum requirements for medi- calent B-I Occupational Safetyand Health Problems for Fire Fighters.Fire 8 hdn evaluation that emplemployee's must to use a P3 g to determine the emp oyee's ability to use a and efnrgenryhatresponse reare very difficultjobs. thesebs respirator. form functionsu are are n perf r and very lyvery onditions. ( ng. These functions arc often performed under very difficult conditions. (See (5) Supplemental information for the PLHCP Appendix C.) Studies have shown that fire-fighting functions require work- ing at near maximal heart rates for prolonged periods of time.Heavy pro- (I) The following information must be pro- tective equipment(including respirators) and the heat from the fire sided to the PLHCP before the PLHCP makes contribute to this physical load. a recommendation concerning an employee's ability to use a respirator. Fire fighters and emergency response personnel also arc exposed to many (A)The type and weight of the respirator to toxic substances during their work.Carbon monoxide is the most common be used by the employee; contaminant;studies have shown individual exposures as high as 5000 ppm in actual fires.Other significant exposures common in fires include cya- (B)The duration and frequency of respirator nide,acrolein,hydrogen chloride,nitrogen dioxide,and benzene.The use(including use for rescue and escape); burning of plastics and other synthetic materials can expose fire fighters to (C)The expected physical work effort: other toxic materials such as isocyanates and nitrosamines.Hazardous mate- rials incidents can involve exposures to many other toxic materials.While (D)Additional protective clothing and equip- the use of respirators helps to reduce exposures,mechanical,environmen- ment to be worn;and tal,and behavior:d factors can limit their use during all phases of a fire. (E)Temperature and humidity extremes that be encountered. (ii)Any supplemental information provided previously to the PLHCP regarding an employee need not be provided for subse- quent medical evaluation if the information and the PLHCP remain the same. (iii)The employer shall provide the PLHCP with a copy of the written respiratory protec- tion program and a copy of this section. Note to paragraph (e)(5)(iii):When the employer replaces a PLHCP,the employer must ensure that the new PLHCP obtains this information,either by providing the docu- menu directly to the PLHCP or having the documents transferred from the former PLHCP to the new PLHCP.However,OSHA does not expect emplqyers to have employees medically re-evaluated solely because a new PLHCP has been selected. (Sher 4of5) 300a Edition 1582-32 MEDICALREQCIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE O EPARTNI ENT PHYSICIANS Table D-1 Comparison of 05HA 29 CFR,Parts 1910.134,"Medical Requirements"and NFPA 1582,Standard on Medical Requirements fir Fite Fighters and Information for Fire Department Physicians,2000 Edition (Continued) NFPA 1582 OSHA 1910.134 24.1 The current member shall be certified annually,or at the request of (6) Medical determination.In determining either the fire department or the member,by the fire department physician the employee's ability to use a respirator,the as meeting the medical requirements of Chapter 3 of this standard in order employer shall: to determine that member's medical ability to continue participating in a• (I)Obtain a written recommendation re bleu-alning or emergency OSfHA standards,such as 29nal CFR 1910.120,�Harardou s WasteO as a member.Any p Pnca- in g the employee's ability to use the ionrespiratorshall dons and Emergency Response"29 CFR I910.I34,"Respiratory Protection," from teen PLHCP.The information: : shall provide only the following information: 29 CFR I910.95.'Oe<upational Noise Exposure,'and 29 CFR I9I0.I030, -Bloodbome Pathogens;shall be followed. (A) Any limitations on respirator use related to the medical condition of the employee.or relating to the workplace conditions in which • the respirator will be used,including whether or not the employee is medically able to use the respirator.; (B)The need.if any,for follow-up medical evaluations;and (C)A statement that the PLHCP has provided the employee with a copy of the PLHCP's writ- ten recommendation. (ii) If the respirator is negative a pressure res- pirator and the PLHCP finds a medical condi- tion that may place the employees health at increased risk if the respirator is used,the employer shall Provide a PAPR if the PLHCP's --- ---- - medical evaluation finds that the employee can use such a respirator,if a subsequent med- ical evaluation finds that the employee is med. ically able to use a negative pressure respirator, then the employer is no longer required to provide a PAPR. (4)Administration of the medical question- naire and examinations. (i)The medical questionnaire and examina- dons shall be administered confidentially dur- ing the employee's normal working houn or at a time and place convenient to the employee. The medical questionnaire shall be adminis- tered in a manner that ensures that the employee understands its content. (ii)The employer shall provide the employee with an opportunity to discuss the question- naire and the examination results with the PLHCP. (Shag 1 of1) MOD Edition APPENDIX F 1582-33 Appendix E Sample Forms Appendix F Referenced Publications This appendix it not apart of the requirements of this NTP.h doe- F-1 The following documents or portions thereof are refer- ument but is included for informational purposes only. enced within this standard for informational purposes only and are thus not considered pan of the requirements of this &1 Physical Exam Summary. The fire department physician standard unless also listed in Chapter 6.The edition indicated can report results of the periodic medical evaluation.which is here for each reference is the current edition as of the date of designed to evaluate a member's continued ability to perform the NFPA issuance of this standard. his or her duties and to detect any significant changes in the condidon of his or her health, on a form like the Physical F-1.1 NFPA Publications. National Fire Protection Associa. Exam Summary.(See Figure Ed.) Lion.1 Batterymarch Park,P.O.Box9101.Quincy,MA02269- E-2 Medical Examination Repo The fire department physi- 9101. rt cian can record information from the medical examination on NFPA IOO I. Standard for FM Rehr Professional Qudifira. a form like the Medial Examination Report.(See Figure E-2) tions.199' edition. F-1.2 ANSI Publications. American National Standards Insti- tute, Inc., 11 West 42nd Street, lath floor, New York, NY 10036. ANSI 53.1,Maximum Pennissibk Ambient Noise Levels forAudi- ometric Test Room- 1991 edition. ANSI 53.6,Specification for Audiometers. 1996 edition. 2000 Edition 1582-34 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PHISICIANS FIGURE GI Form for Eve department physician's report. Physical Exam Summary Employer Employee's Name: Position Tide: Date of Exam: Examining Physician: Abnormal, Abnormal, Significant Changes Components Within Normal Able to Perform Unable to Perform Noted from Previous Performed Limits Job Tasks Job Tasks Exam(it applicable) ❑ Physical exam ❑ Audiograrn ❑ Pulmonary function ❑ Treadmill stress ❑ EKG-121ead ❑ Chest x-ray ❑ Mammogram ❑ Pelvic/Pap ❑ Laboratory tests ❑ Other Explanation of Abnormal Results/Significant Changes: ❑ Medically cleared to perform job tasks ❑ Denied medical clearance for current job tasks nrr a mauls'Exam Swami, a 2) 20E0 Edition APPENDIX F 1582-35 FIGURE E-1 (Continued.) H of P.1.: Mr./Ms. is a v.o.Fire Fighter Police Officer with the department.The purpose of this annual physical is to establish fimess for the continuation of those duties.He/she has enjoyed good health.Mr1Mrs. voiced the following questions: Medical History Surgical History Medications _ D.M. —Orthopedic _ HTN _ENT —CVD _Optho — Asthma —Other Allergies Social History ROS _Smoke GI PPD _Hematochezia -Quit _Stool caliber PkYr _Bowel habits Exercise —Alcohol G.U. Amount _Stones -Frequency _Hematuria CV Chest pain SOB Resp _Cough Wheezes SOB FH Physical Audio- DM Insert physical here _HFHL HTN _Speech range - CVD Vision EKGTMT Blood _Near _HR H/H_ _Far _Target WBC_ _ Corrected _Intesp Glu_ Stool OB —Stage achieved Chol_ HDL Positive Pulm Ratip_ — Negative FVC Risk_ %Pred UA LFTs _ Blood FEW SCOT_ _ Protein %Fred SOFT _Glucose GGT_ Other PrPA mpg*Ian Summary la 04 2000 Edition 1582-36 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PHYSICIANS FIGURE E-2 Medical examination report form. Medical Examination I. NAME(Last) (First) (Middle) 12.SEX 3.DATE OF EXAMINATION 4.PLANT OR DIVISION 5.SOC.SEC.OR 6.OCCUPATION 7.DATE LAST EXAMINATION EMPLOYEE NO. 8. REASON FOR PRESENT EXAMINATION 0 PRE-PLACEMENT 0 D.O.T. ❑ SIRdVPIT t ANCE ❑ IMMIGRATION ❑ F.I.T. 9.TEMP. W.PULSE 11.BLOOD PRESSURE 12.HEIGHT 13.WEIGHT 14.'LI'fMUS SNELLING FT IN. 15.VISION UNCORRECTED CORRECTED l6.COLOR VISION (Use Cade)" DISTANT RE 20/ BOTH LE 20/ RE 20/ BOTH LE 2O/ NEAR RE 20/ BOTH LE 20/ RE 20/ BOTH LE 20/ 17.PERIPHERAL Clinical Evaluation Area Examined •Use Code Remarks(Describe all"Code Is"in detail) 18. Head and neck 19. Thyroid - Lymph nodes 20. Eyes Fundi 21. Ears 22. Nose and sinuses 23, Mouth and throat 24. Teeth 25. Chest and lungs Breast 26. Henn • 27. Abdomen 28. Inguinal,e.g..hernia 29. Genitalia •Code: 0—Within normal limits 1—Significantly abnormal X—Not examined NFPA Medea/FawnLvtlan Form(I 0112) 2000 Edi0on APPENDIX F. 1582-37 FIGURE E-2 (Continued) 30. Pelvis 31. Anus and rectum Prostate Proctoscopic 32. Spine 33. Skin 34. Arms Hands 35. Legs Feet 36. Peripheral-Vascular 37. Neurologic 38. Emodonal status 39. Other 40.Urine dip: Glucose: Albumin: S.G.: • Heme: Leukocyte-Esterase: Other 41.Flex 42.Step test 43.Body fat 44.PFT 45.Audio 46.Chest x-ray(use 0, 1.or X) 47.EKG(use 0, I.or X)and specify test used 48.Hemocult 49.Back eval. 50.Tetanus 51.PPG 52.Stress test 'Code: 0—Within normal limits I—Significantly abnormal X—Not examined NFPA Me4lcI[umlMbn Farm(1 al 12) 2000 Edllbn 1582-38 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPMThIENT PHYSICIANS FIGURE E-2 (Continued) i 53.Other x-ray or laboratory findings I j 54.Physician's summary,remarks,and diagnoses,including recommendations made to patient (include code numbers for diagnoses and conditions found) 55.Recommendations/Restrictions 56.R.N.signature 0 ❑ 57.Physician's signature 0 58.Patient's signature 59.Work qualification: 60.Contact person: 61.Due: 62.Initial: •Code: 0—Within normal limits I—Significantly abnormal X—Not examined SEna YMlul Esam W aan Ern is or I'a) # 20OO Edition APPENDIX F 1582-39 FIGURE E2 (Cmuinued.) Health History Yes No If"Yes,"Give Details. Have You Had Any Surgeries/Operations: On your back ann.leg,or knee? ❑ 0 To treat a hernia? 0 0 Varicose veins? 0 0 Other operations? 0 0 Have you ever been hospitalized? 0 ❑ Allergy—HaveYou Ever Had or Do You Currently Have: Serious allergy? 0 0 Bad reaction to any medication? 0 0 Advised not to take any medication (e.g..aspirin)? ❑ ❑ Skin—Have You Ever Had or Do You Currently Have: Hives/eaema or rash? 0 0 Chronic skin problems(e.g..cuts slow to ❑ ❑ heal)? Excessive skin dryness? 0 0 Problems with"easy bruising'? 0 0 Chemical or jewelry rash/sensitivity? 0 0 Neuro—Have You Ever Had or Do You Currently Have: A psychiatric or emotional problem? 0 0 Numbness/weakness/paralysis? ❑ 0 '‘Dizziness or feinting spells? 0 0 Severe/frequent or migraine headaches? ❑ 0 Head injury,concussion,or skull fracture? ❑ ❑ Neurological disorders? ❑ 0 Seizures or blackouts? 0 0 Stroke? 0 0 Eyes/Ears—Have You Ever Had or Do You Currently Have: Hearing loss? 0 0 Frequent ear infections? 0 ❑ NM Medical e.enln.aOa F (4 a I21 2000 Edition 158219 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PHISICLANS FIGUREE-2 (Continued) Health History Yes No If"Yes,"Give Details. Ringing in ears? 0 ❑ Other ear problems? ❑ ❑ Glaucoma or cataracts? ❑ ❑ • Red eyes? ❑ ❑ Eye injury/vision loss? 0 El Other eye problems(e.g..strain from VDT use)?❑ Glasses/contacts? ❑ ❑ ( Date of last vision screen? ❑ ❑ Head/Neck—Have You Ever Had or Do You Currently Have: Date of last dental exam: ❑ ❑ _ Recent problems with teeth/dentures? ❑ ❑ Frequent mouth ulcers/infections? 0 ❑ Sinus or hay fever? ❑ ❑ Frequent sore throats? ❑ ❑ Frequent nose bleeds? 0 ❑ Trouble with thyroid(e.g.,taking thyroid ❑ ❑ medication)? Problem requiring radiation treatment to ❑ ❑ the neck area? Lungs—Have You Ever Had or Do You Currently Have: Asthma or wheezing? ❑ ❑ Coughed up any blood? ❑ Shortness of breath without apparent reason? ❑ TB or a positive skin test for TB? ❑ Pneumonia or pleurisy? ❑ ❑ Do you cough every day,especially in ❑ ❑ the morning? Pain or tightness in chest? More than three episodes of bronchitis in El 0 one year? Ever smoked tobacco in any form? How long: Yrs. Packs per day: When quit: Had a chest x-ray? 0 0 Last time: NFRA Medical Exasn+l0a Form IS of II) 2000 EOnon APPENDIX F 1582-11 FIGURE E-2 (Continued.) Health History Yes No It"Yes,"Give Details. Heart—Have You Ever Had or Do You Currently Have: Rheumatic fever or heart murmur? ❑ ❑ Heart disease? ❑ ❑ Treated for heart condition? E ❑ Unusually cold or bluish-colored hands ❑ ❑ or feet? High blood pressure.If"Yes,'how is it ❑ ❑ Q Medicine CI Diet 0 Exercise •treated? Do you have a history of elevated cholesterol? ❑ ❑ Anemia or any blood disease? ❑ ❑ Phlebitis,varicose veins-or blood clots/ ❑ ❑- poorcirculation? Chest pain with activity? ❑ ❑ GI—Have You Ever Had or Do You Currently Have: Ulcers? ❑ ❑ Hiaul hernia? ❑ ❑ Indigestion,pain,or unusual burning in stomach? ❑ ❑ Vomiting of blood? ❑ ❑ Bloodyharry bowel movements? ❑ ❑ Colitis or nervous stomach? ❑ ❑ Yellowjaundiceorhepatitis? ❑ ❑ •Problems with your pancreas? ❑ ❑ Gallbladder disease? ❑ ❑ Kidneys—Have You Ever Had or Do You Currently Have: Bladder or kidney infections? ❑ ❑ - Kidney stones? ❑ ❑ Burning or discomfort on urination,or frequent urination? ❑ ❑ Hernia? ❑ ❑ Blood in urine? ❑ ❑ It e.enl Ra.mwam roam la al tat WOO Eaton 1582-42 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PHYSICLANS FIGURE E,2 (Cmrtinuedl Health History Yes No If"Yes,'Give Details. Miscellaneous—Have You Ever Had or Do You Currently Have: Diabetes or sugar in your blood or urine? ❑ ❑ Cancer of any kind? ❑ ❑ Muscle-Skeletal—Have You Ever Had or Da You Currently Have: Arthritis,rheumatism,neck,back,or spine injury or disease? ❑ ❑ Been treated for a back problem? ❑ ❑ Recurrent stiffness or back pain? ❑ ❑ Bursitis,rendonitis? ❑ ❑ Recurrent pulled muscles or sprains? ❑ ❑ - Hand or wrist injury or problem? ❑ ❑ Hip or knee injury or problem? ❑ ❑ Ankle or foot injury or problem? 0 0 Frostbite? ❑ 0 Job requiring heavy lifting or standing,or 41 sitting for long periods of time? 0 0 Any broken bones? ❑ ❑ For Females Only—Have You Ever Had or Do You Currently Have: Menstrual irregularities? ❑ ❑ • Recurrent problems of the female organs? ❑ ❑ Breast masses or lumps? 0 ❑ Do you practice monthly breast self-exam? ❑ 0 Haveyoueverhadamammogram? ❑ ❑ Date of last pap smear. ❑ ❑ For Males Only—Have You Ever Had or Do You Currently Have: Prostate or testicular problems? ❑ ❑ Breast tenderness,swelling,or lumps? ❑ 0 Do you practice monthly testicular self-exam? ❑ ❑ NPM marts 4sSnaean Fenn rte.ul 2000 Milan APPENDIX F 1582-43 FIGURE E-2 (Continued.) Health History General Lifestyle I. (check the answer that but describes yoa.) General health 0 Poor 0 Fair 0 Good 0 Excellent %Seatbelt use 0 0-2496 0 25-49% 0 50-74% 0 75-I00% Daily stress 0 Low 0 Moderate 0 High Avenge hours sleep 0 6 hours or less 0 7-8 hours 0 8 hours or more Avenge meals daily 0 I meal 0 2 meals 0 3 oc more 'Number of eggs per week 0 0-I 0 2 0 3or more Avenge number red meat meals per week 0 0-1 0 2-3 0 3 or more Avenge number of alcoholic beverages/beers 00-5 06-14 015 or more per week Yes No- If"Yes,"Give Details. Do you exercise three times per week? ❑ ❑ 30-40 minutes each time? ❑ ❑ Identify types of exercise. Are you more than 30%above your ideal weight? ❑ ❑ Have you received a tetanus booster in the last 10 years? ❑ ❑ Have you been immunized against hepatitis B? ❑ 0 Year immunized: Do you take any prescription medication? ❑ ❑ Do you take nonprescription medication(or over-the-counter drug)on a regular basis? ❑ ❑ General Lifestyle II. Do you participate in a workplace wellness/ ❑ ❑ help promotion program? Which of the following would you like m see offered and would you participate in? Cholesterol screen ❑• • ❑ Blood pressure screen ❑ ❑ Weight loss ❑ ❑ Nutrition program ❑ ❑ Stress management ❑ ❑ Smoking cessation ❑ ❑ CPR ❑ ❑ urea ueaa rareweaa,roan petit) 2000 E4den 1582-14 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PHYSICLVIS FIGURE 62 (Continued.) Health History Yes No It"Yes,'Give Details. L• Blood drive ❑ ❑ Health risk appraisal ❑ ❑ Self-directed exercise ❑ ❑ Health education program ❑ ❑ Women's health ❑ ❑ Work History I. Have you ever. .� Been restricted in your work or given"light duty"because of your health or injury? ❑ ❑ Left ajob because of health problems? ❑ ❑ Been injured on the job and treated by a doctor? ❑ ❑ Received compensation for an industrial injury or illness? ❑ ❑ Are you receiving any health care treatment (e.g..physical therapy,chiropractic, acupuncture,medical,etc.)? ❑ ❑ Been1i s iialzed in the last five years? ❑ ❑ • Have you had any illness or injury that we have not asked you about? ❑ ❑ Work History II: Do you have hobbies,such as furniture reFm- ishing,painting,hunting,shooting,or model building? ❑ ❑ Do you moonlight or have a second job? ❑ ❑ Work History!IL Exposures—HaveYou Ever Worked Around the Following: Chemical plant? ❑ ❑ Coke oven? ❑ ❑ Co.^:tmction? ❑ ❑ Cotton,flu,or hemp mill? ❑ ❑ Electronics plant? ❑ ❑ Farm? ❑ ❑ Foundry? C ❑ Rrwwaa Eumaueen ram co at In 2000 Edition APPENDIX F 1582-45 FIGURE E.2 (Continued.) Health History Yes No It"Yes,"Give Details. Hazardous waste industry? ❑ ❑ Hospital? ❑ ❑ Lumber mill? ❑ ❑ Metal production? ❑ ❑ Mine? ❑ ❑ Nuclear industry? ❑ ❑ Paper mill? ❑ ❑ Pharmaceutical? ❑ ❑ Plastic production? ❑ ❑ Pottery mill? ❑ 0— Refinery? ❑ ❑ Rubber processing plant? ❑ ❑ Sand pit or quarry? ❑ ❑ Service station? ❑ ❑ _ Shipyard? ❑ ❑ Smelter? ❑ ❑ Have You Ever Worked With or Been Exposed To: Aldrin? ❑ ❑ Arsenic? ❑ ❑ Asbestos? ❑ ❑ ,Benzene? 0 ❑ ' Benzidine? ❑ ❑ Beryllium? 0 0 BIS chlommthyl ether? ❑ ❑ Cadmium? 0 ❑ Carbon disulfide? ❑ ❑ Carbon tetrachloride? ❑ 0 Chlorine? ❑ 0 Chlorodane? ❑ ❑ Chloroform? ❑ ❑ NFPA r.ecai Examination Farm(10 al 12) 2000 Edition 1582-46 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PHYSICIANS FIGURE E2 (Continued.) Health History Yes No It"Yes,"Give Details. Chlomptene? ❑ E Chromates? ❑ ❑ Chromic acid mist? ❑ ❑ Cutting oils? ❑ ❑ DDT? ❑ ❑ Dieldrin? 0 0 Dioxin? ❑ ❑ Dust,coal? 0 0 Dust.sandblasting? ❑ ❑ Dust.other? ❑ 0 Ethyl dibromide? 0 ❑ Ethylene oxide? ❑ ❑ Extreme heat or cold? ❑ D Heptachlor? ❑ ❑ Hexachlombenzene? ❑ ❑ Isocyanmes(TN,MDI)? ❑ 0 Loud or continuous noise? ❑ 0 Mercury? 0 ❑ Methylene chloride? ❑ ❑ Microwaves,lasers? ❑ ❑ Nickel? ❑ ❑ PCBs? ❑ ❑ Pesticides,herbicides? ❑ ❑ Phenois? ❑ ❑ Phosgene? ❑ ❑ Plastics? 0 0 Radioactive materials? ❑ ❑ Roofing materials? ❑ ❑ Rubber? ❑ ❑ Silica? ❑ ❑ NFPA M.WcI aumFelbn Fenn 411 a 12) 2000 EOWan APPENDIX F 1582-47 FIGURE E-2 (Continued) Health History Yes No If"Yes,"Give Details. Solvents/degreasers? ❑ ❑ Soots and tars? ❑ ❑ Spray painting? ❑ ❑ TRYPER chloroethylene? ❑ ❑ Vinyl chloride? ❑ ❑ List any toxins/chemicals/biological hazards you might currently be exposed to: Work History IV. Jobs—Start with the Most Recent: Date(Year to Year) Company Position Any Work Hazards I certify that the above information is true and complete to the best of my knowledge.I hereby give permission to release work-related information to the proper authorities of my employer or the company for which I am ajob applicant. Date: Signature: Examiner: xrw Medical Ess MMen rpm(II e/sal 2E00 Eaton 1582-18 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPARTMENT PMSICIANS Index 02000 National Fire Protection Asociadon.Al Rights Reserved. The copyright in this index is separate and distinct from the copyright in the document that it indexes.The licensing provisions set forth for the document an not applicable to this index.This index may not be reproduced in whole or in part by any means without the express written per. mission of the National Fire Protection Association.Inc. A- -F- Abdominal organs 39,A-19 2 Fire department Adminisnton,guide for fin deparment App.D Guide for administaton App.D Advanced life support(ALS) 522,A-54.1.A-5-2.2 Members nrMemben And-discrimination laws D-1.2 Fire department physician 2-2.A-2-2:see also Medical enluadons Approved(defmidon) 14.I.A I4.1 Choosing 22.2.A-2.2.2.D3 Asthma B-3.2 Definition 14.10 Audiometry B-2.3.2.4 Immunizations.responsibility for 41 - Authority having jusssdicdon(definition) 142,A-14.2 Incident scene treatment.role in 13.".A-SL1 to A-SI.2 A33.2 Infection disease control,role in 412.A+2.1 Basic life support(ELS) 5.0 0 A-S"2 Information for App.B Blood and blood-f«mmg organ 3-15,A-3-15 Record keeping and reports of 2-6 Blood exposures 42.I.A+21 Functional opacity evaluadm B-2.6 Moodbome pathogen exposure,post-exposure prophylaxis for A+4.1 Definition 14.I1 Body Quid exposures 4-2.1,A+2.1 Burn injury A-5-3.2 -G Gashointesdnal systems 39,A-3-9.2 -C- Genitourinary enema 3-10.A-110,0-3.4,D-1.4 Dancer risk B-1.4 Candidates -H- '. Definition 14.3.M14.3 Head 3-2.1,A32.12 Medici evaluation 2-l.2-3,A-2-1,I.A-Y-I.S.A-2-3 Heath and finks coordinator 2-2.4 Category A medical condition see Medical conditions Definition 14.12 Category B medical condition see Medical conditions Health and safetyofffca 2-2.4 Chemicals 3-20,A-3-20.2 Definition 14.13 Chest wall Sy.A-ly Hearing 3-4.A-34.2,e-1.4.B-2.3.2.4.B-3.5 Confidentiality,medid evaluations 26 Heart 33.1.A-38.1,B-1.2.B-1.4,B-2.1 to B-2.2,B-2S2.5,B-3.3 Hepadda B Immuniadone A44 .p. Dental 33.A35.2 "I- Diabetes mellitus B-3.1 Immunizations 44,A44 Disabled persons D-l.I Implemewdon of standard 1-3,A-13.2 Down member .A-5-3.2 Incident commander 5-1.2.52.1,A3-4.4 Drip 3-20,A4-20.2 Incident safety officer 5-2.1 Definition 14.6 Incident scene rehabilitation and medical treame st...Chap.5,A3 Infection control officer 41.2 Definition 1414 Ears 34.A34.2 Intention conhol program(infectious and communicable Electrocardiography B-2.2,B-2.3.2.5 disease control) Chap.4.A4 - Emeigency medical services(EMS) 5-2.2,53,A-SLI Definition 14.15 A-12.2.A-5-3.2 Definition 14.13 Endocrine disorders 3-16,A-3-16 Laboratory tots B-2.3.2.1 Epilepsy B3.6 Lynx 36,A36 Esophagus 36,A-3-6 Lepl considerations D'1 • Essential job functions(structural rue-fighting) App.C Lungs t 34,A-3-7.8-2.3.2.3.032 Definition 1-4.7 Evaluations see Functional capacity evaluation; Medical evaluations Malignant diseases 3-18,A-3-18.2 Exposure incidents 9-2,A4-2 Medial confiding Definition 14.9 CategoryA Chap.3,A31 we also specific body part Extremities 3-12,A312.2 and conditions Eyes 13,A-3-3 Definition 14.9 2000 Edigdn INDEX 1582-49 Category B Chap 3.A-3:see Wmspecific body - P- partsandconditions Personnel accountability system 54.8 Definid0n 14.5 Phyical load,of fire-fighting functions B4.2 Specific b3 Physician sn Fire department physician Medical evaluadot Post-exposure prophylaxis A+Y.I to A-442 Content of 62.3 Pregnancy 13.3.4.D-1.4 Coordination of program 0.3 Protected classes 0.1.3 Definition 1416 Psychiatric condidons 319.A-3-19.2 Guidance for B-2 Pulmonary function tearing B-2.3.23 Incident scene 5.3,A-5-3.2 Purpose of standard OSHA 1910.134 compared Table D4 .R. Penodic 2-1.2.24,A-24,B-2.2 Freplacement and base line Reactive airways disease63.2 ProcessYd, -3.A-2,A-2.1.5 Referenced publcadom Chap.6,B-4.App.F Reports and records Records,result,reporting.and confidentiality 26,B-2.4 Exposure incidents 4-2,43.2,A-F?.A-432 Sample forms.medical examinations. App.E Immunization records A44 Retumtoduty %I 2.25,A-25.I.A-2-5.3 to 43.5.4 Medical evaluations 25 Tactical level management component(TLMC) 54.5 Sample forma,medical examinations App.E 5-4.7,A-5-4.5 Medical examinations s alto Medical mluatiom Reproductive system }IO.I.A-}IO.t.Y.B-3.4.0.1.4 Component of b2.3.2 Respiratory disease risk B4.4.13-2.9 2.3,19-9.2 Definition 14.17 RMk }ll.h}IL2 Sample forms App.E R4 8-I.4 Medical history 62.3.1 S. Medici process Chap.2.A-2 Sacroiliac joints 5I1.AS41.2 Medical service,emergency in Emergency Sample form App.E medical service(EMS) Medically certified Scapulae 341,A-}I I.2 Definition 14.19 Scope of standard 1-I Periodic medical evaluation 24.A34 Second opinima &2.4 Preplacement medical evaluation 23,A-2-3 Scam b9b Reports 2-6.2 to 25.9 Shall(definition) 1421 Should(deflniden) 14.22 Retumta-duty medical evaluation 2142 to 2.4.5,A-25.3 Sldn 3-14.A-114.2 Medications 3-20,A-3-20.2 Smoke Inhalation A53.2 Members Spine 311.A-3-11.2 Current Standard(definition) 14.23 Definition 14.20.1 Stress tasting B-2.2 Medical evaluations 24.24,A-2-t.l.A-24.5,A-24 Systemic disease .346,A-3-17.2 Definition 14.20,A-1420 Down A-5-5.2 "Incident scene rehabilimdon and Tactical level mmagemmt component(TLMC) 54 medical treatment Chap.5,A-5 A-54.3 to A-54.5 Infection control program Chap.4,Ali DeF ition 14.24 Occupational safety and health problems 0-3.Table D4 Toxicsobmces B-IJ.8-1.4.B-3.4 Metabolic disorders 9I6.A-3-16 Trachea %.A•% Murnlo.kele l system A33.2,B-2.6 Tape,incident scene }!.A-}!.2 Tuberculosis 43,A-4-3 .N. Tumors " 3I3.A-3-18.2 Neck..... 9-2.2,A-3-2.2.2 .U. Neurologi l dilorden 343.ASIS Nose 3-6.A-3-6 Urinary sstm 3I0.2.A-3-10.2.2 4 OmpatioW history B-2.S.1 Vascular spare %.Y,A-%.B-1.4.bl.J Occupational Safety and Health Admisistradon Vision 3-9.A-}! (OSHA) 1910.134 comparison Table D4 Occupational safety and health problems B-I,Table D-4 Oropharyna %,A-% X-rays 6-2.2.B-2.5.2.2 Cou/W 2000 Edition nC Rri CERTIFICATE OF LIABILITY INSURANCE DATEa�BD4Yyy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the p011cy(lee)must be endorsed. If SUBROGATION IS WAVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endanementl4). PRODUCER Cr ONTACT Joseph Santiago,CPIA,CPU,PIAM Advanced Professional Services INc�NP,Em: (854)T256112 11A'C.Ngt: (954)7256115 240 Lock Road ADDRESS' want ago@advancedprolessional.wm I Deerfield Beach,FL 33442 INSURERISI AFFORDING COVERAGE RAC• Phone (954)7256112 Fax (954)725-6115 NSURER A: Lancet Indemnity INSURED NSURER B: _ Gilbert Shapiro,MD NSURER C 540 Truman Ave. NSURER D: Key West,FL 33040 (305)296-9145 NSURER E NSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I UP LBNR AODLSUBTYPE OF INSURANCE INSR WVD' POLICY NUMBER IMAM IDDIYYYYI l MNDYIYYYYI UXRS GENERALLIASRJIn EACH OCCURRENCE UCOMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED I� DAMAGE ye RENTED n I_I CLAIMS-MADE OCCUR MED EXP(Any one person PERSONAL P.ADV INJURY ❑ GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG POLICY El Pi, C1 we RI MANAGEMENT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT BY (Ea araeeml Ll ANYAUTO-- ��. ��,� BODILY INJURY(Per person)❑ ZONEDglcliguyED _ -. BODILY INJURY Wei-accident $ d HIRED AUTOS ❑ NON-OWNED WNVaR Wlq. YEB= ' PROPERTY DAMAGE $ UMBRELLA LIB Ti OCCUR EACH OCCURRENCE $ ILi EXCESS LIAR U CLAIMS-MADE AGGREGATE S L� DED ❑ RETENTION S _ _ _ _ $WO AND EMPS EMPLOYERS' LIATOX TORY LIMITS ❑ET' ANY PM%RIETOR'PARTNItt YIX ANY OFFICER/MEMBER EXCLUDED'ECIRIVE NIA ELEACX ACCIDENT i (Mandatory In NH) E L DISEASE-EA EMPLOYE 8 Ifyes besabe under DESCRIPTION OF OPERATIONS below E L DISEASE.POLICY LIMIT $ A I Medical Professional Liability LI091289001415 07/012013 07/01/2014 $250,000 Eacw$750,000 Aggregate DESCRIPTION OF OPERATORS I LOCATIONS/VEHICLES Attach ACORO 101,Addional Remarks Schedule,it mere space is unwired) Specialty:Family Practice-No Surgery Endorsement:Stephanie A.Gallaher,ARNP CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Monroe County Board of County Commissioners THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 500 Whitehead St. AUTHORIZED REPRESENTATIVE Key West,FL 33040- ©1900-2010 ACORD CORPORATION. All rights reserved. ACORD 2512010/05)OF The ACORD name and logo am registered marks of ACORD arse RoRD CERTIFICATE OF LIABILITY INSURANCE DATE (MMDD"WYI ti-- ' 03/26/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: Ifthe certificate holder is an AOOITONAL INSURED,the policylies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights tithe certificate holder in lieu of such endORementls). PRODUCER oOYE°0T Joseph Santiago,CPIA,CPII,PIAM Advartal Professional Services PHONIa L Ertl; (954)725-6112 FAX (954)7256115 •1240 Lode Road AADDIASS- jeamiagoegaaancedprolessional.wm Deerfield Beach,FL 33442 INSURERISI AFFORDING COVERAGE NPM B 1 Phone (954)725-6112 Fax (954)7256115 INSURER A: Lancet Indemnity RRG INSURED INSURER B: Elias J.Gerlh,MD INSURER C: 540 Truman Ave. INSURER D Key West,FL 33040 INSURE---__ INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADM-USRr POLICY EFF POLICY EXITLTp TYPE OF INSURANCE IRSR WVD POLICY NUMBER IMMDDIYYYVI IMMDWWYY) LIMITS GENERAL LABILITY EACH OCCURRENCE 250,000.00 �� COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED I r� PREMISES RENTED L L CLAIMS-MADE OCCUR I LR0912120013554 MED EXP(Any one person A iII Medical Professional 05/01/2013 05/01/2014 PERSONAL ADV INJURY I Liabiillly Insurance GENERAL AGGREGATE 750,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG ' GE L . POLICY El d [H LOL i - e AUTOMOBILE W&IIIY COMBINED SINGLE LIMIT(Ea acadefl11 S ANY AUTO A�pGFN1ENf BODILY INJURY Perwnonl S. qu n cHEom GwNEU sao D Rl'1 BODILY INJURY IPer a ' s TGR NON- ❑ HIRED AUTOS LiAONWNEO PROPERTY DAMAGE ) ❑ ❑ BY s u UMBRELLA LAB ❑OCCUR DA YES— EACH OCCURRENCE E N ❑ EXCESS LIAR 7 CLAIMS-MADE WAIVER . AGGREGATE $ C CED C RETENTIONS S WORKERSµ COMPENSATION ❑ WC STATUS —I ETH EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E,L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED', j 1 NIA IMyanWbry In NHee ` E L DISEASE•EA EMPLOYE S ID ESCRIPTION OF OrPE RATIONS below E L.DISEASE•POLICY LIMIT S • DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,AMNorul Ramat Schedule,II more space Y rewind) Spedalty:Internal Medidne-No Surgery CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Monroe County Board of County Commissioners THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, 500 W hltttead St. AUTHORIZED REPRESENTATIVE Key West,FL 33040- ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105)OF The ACORD name and logo are registered marks of ACORD A�R?� CERTIFICATE OF LIABILITY INSURANCE I DATEa�6/IYYYY, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the polirylles)must be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights tithe certificate holder In lieu of such endorsemenga). PRODUCER CONTACT Joseph Sansaga,CPIA,CPII,PIAM NAME: Advanced Professional SeMm PHONE y N EAti (954)725E112 FAX INC Nol: (954)725-6115 200 Lock Road ADDRIESS. Isamlago advancedprolessionaI.com Deerfield Beach,FL 33442 INSURERISI AFFORDING COVERAGE NAIC• _ Phone (954)725-6112 Fax (954)725-6115 INSURER A: Lancet Indemnlly INSURED _INSURER B: Timothy W.Mackey,DO INSURER C: 540 Truman Ave. .INSURER 0: Key West FL 33040 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREhENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTIRR TYPE OF INSURANCE INSR WVD'I POLICY NUMBER PoDDYEFF MMIOPOLICY E%P UMITS IMOLICI EFF 1 MMNDM'WI. GENERAL LIABILITY j EACH OCCURRENCE 250,000.00 DAMAGE TO RENTED C ' El GENERAL LIABILITY PREMISES(Es occurrence)) J C CLAIMS-MADE I OCCUR L1091212001739 MED E%PlAny one person A II 10/02/2013 10/02/2014 K. Medical Proressional , PERSONAL a ADV INJURY Li Liability Insurance I GENERAL AGGREGATE 750,000.00 GEM.AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG C POLICY 'iI !Ea ❑ LOC I AUTOMOBILE WWLRT ' COMBINED SINGLE LIMIT $ I Li ANY AUTO BODILY INJURY(Per person) S GALLOWNEO SOHWULEO HIRED I NuioG �^^ BODILY INJURY(Per accident $ El AUTOS oNOWNEO p BV RI NAGEMENT OPERTY DAMAGE s os it q 0Yr $ L_ UMBRELLA LAB r OCCUR /��] I EACHOCCURRENCE S L_ EXCESS UAB f CLAIMS-MADE DATE v�-a —FL AGGREGATE S QED Li RETENTION$ WAIVER W ,Wit_ s WORKERS COMPENSATION j TDRYTTU- i OERH AND EMPLOYERS'LIABILITY YIN ANY OFFICER/MEMBER ER EXCLUDED'ECIRIVE NIA ELEPLH ACCIDENT 8 (Mandatory In NHI E.L.DISEASE-EA EMPLOYE $ DESCp mRIPTON Osmea under F OPERATION eoelon' EL DISEASE.POLICY LIMIT $ • DESCRIPTION OF OPERATIONS LOCATIONS/VEHICLES (Attach ACORD 101.Additional Remarks Schedule,If more space Is required, Specially:Urgent Care CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Monroe County Board of County Commissioners THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 500 Whitehead St ADTHORaED REPRESENTATIVE Key West,FL 33040- L. ©1989-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD