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04/20/2011 AgreementDANNYL. KOLHAGE CLERK OF THE CIRCUIT COURT DATE: May 13, 2011 TO: Teresa Aguilar Employee Services r ATTN: Christine Diaz FROM: Isabel C. DeSantis, D. C. At the April 20, 2011, Board of County Commissioner's meeting the Board approved the following: Item C20 Contract for Employment Physical Services with Michael D. Burton, D.O. Item C21 Contract for Employment Physical Services with Ronald Samess, M.D. Enclosed are fully executed copies of the above -mentioned for your handling. Should you have any questions please do not hesitate to contact this office. cc: County Attorney Finance File MONROE COUNTY CONTRACT FOR EMPLOYMENT PHYSICAL SERVICES THIS AGREEMENT ("Agreement") is made and entered into this 20th day of April, 2011, by MONROE COUNTY ("COUNZY" ), a political subdivision of the State of Florida, whose address is 1100 Simonton Street, Key West, Florida 33040 and Ronald R. Samess, M.D. ("CONTRACTOR"), whose address is f Professional Centre, 5701 Overseas Highway STE. 17, Marathon, FL 33050. 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: Ronald R. Samess, M.D. 1st Professional Centre r 5701 Overseas Highway, STE. 17 = Marathon, FL 33050 - Phone: 305-743-2253 -< Fax:305-743-5383 � o D. All urine screens will conform with the standard chain of custody protocols _J mandated by state and federal regulations. r5 f E. The Contractor will have an employee designated as coordinator'&i -, — facilitator to assist in the communications with the Monroe Courttj 66CCt; 0 o primary contact personnel. F. Appointments will be available throughout the business hours of the facility: Monday - Friday 9:00 a.m. - 5:00 p.m. Closed 12-1:30 for Lunch Fridays: Physician leaves at noon. Facility open until 3:00 p.m. for procedures, such as drug screens, which do not require a physician be present. Walk-ins will also be accepted if an appointment cannot be reasonably scheduled. G. Appointments will be seen by the contractor in a reasonable and timely fashion. H. The Contractor will provide the County with at least a 24 - 48 hour 2 turnaround time for the receipt of any drug or physical results. I. 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. Bart of the recluirenieiits set Barth by the sti:ate of Florida dru free tivorkpl ace policy, which NIonroe County has adopted, and the Departnicrat of Transportaation, Ille coauaty ralu;;t have a yuali lied kl(:dical Re4 icw Otticcr `AlRo)" perform dru- -vicus. rIhe X114) rs:ceitie5 lab reports tionl the laboratory (as (J0%C11('d by regaalati0ns); Review-, lab reports for integrity, wthentlk:ity, liaise ne "".1tives, "and false Positir es; interprets late results. including veritication +flab positives; reports lah reports to the culplo�ler (as defined by rules MId rc �rl,ations). J. 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. K. 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 initial Agreement term will be for one (1) year beginning the 20th day of April• 2011 and renewable at the County's option for two (2) additional consecutive one year terms. 4.2 The terms of this Agreement shall be from the effective date hereof and continue for a period of one year. This Agreement shall be automatically renewed for successive one- year periods until either party gives the other notice of cancellation in accordance with the terms set forth below. The Contractor must provide the Contractor with at least thirty (30) days notice of intent to terminate. If either party desires to modify this Agreement, it shall notify the other in writing at least thirty (30) days prior to the effective date of such modification. In the case of proposed modification the party receiving the notification of the 3 proposed modification shall itself notify the other party within ten (10) days after receipt of notice of its agreement to the proposed modification. Failure to do so shall terminate this Agreement. 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. COUNTY may terminate this Agreement with or without cause upon thirty (30) days notice to the CONTRACTOR. COUNTY shall pay CONTRACTOR for 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 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: Ronald R. Samess, M.D. 1st Professional Center 5701 Overseas Hwy, STE. 17 Marathon, FL 33050 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 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 a 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. 5 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 attorney'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 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. on 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 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. 151 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 bonafide 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 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 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 0 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 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. 10 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 advise 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. 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, attorneys 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 11 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. ESS WHERE F, the parties hereto have caused these presents to be executed on the k i of 201 l L. KOLHAGE, CLERK NROE COUNTY, FLORIDA r 0 Wo Deputy Clerk (CORPORATE SEAL) ATTEST: By 12 BOARD OF COUNTY COMMISSIONERS by*0, ayor/Chairman RONALD R. SAMESS, M.D. by------- Title: r'✓l0NRE COUNTY ATTORNEY AP �r0�.! AS T ASSISTF/',t. "ATTORNEY SECTION ONE SCOPE OF SERVICES EMPLOYMENT PHYSICAL SERVICES The scope of services to be provided on an as needed basis by the Provider and 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, and Lab, be performed by the physician and *MRO review) 10 panel will be either scheduled or done on a $35.00 State Requirement walk-in basis. DRUG SCREEN: When requested, a drug screen will (Collection and Lab, be performed by the physician and *MRO review) 5 panel will be either scheduled or done on a $35.00 Department of walk-in basis. Transportation Requirement *MRO REVIEW Drug screens will be forwarded to N/A Dr. Burton for MRO review. Dr. Burton will bill Dr. Samess directly for payment of MRO review. BLOOD ALCOHOL When requested, Blood Alcohol (Collection, Lab, MRO Screens will be performed by the review) physician and will be either N/A scheduled or done on a walk-in basis. A testing facility must be available 24 hours a day, 7 days a week for post accident, random, and reasonable suspicion alcohol screening. BREATH ALCOHOL (if When requested, may be used for available) screening. If breath alcohol screen is positive, a blood screen will be N/A performed. 13 If Physician wishes to propose other means of screening method, please provide testing method explanation and accuracy. A testing facility must be available 24 hours a day, 7 days a week for post accident, random, and reasonable suspicion alcohol screening. PPD- TB screen When requested, a PPD-TB screen will be scheduled and performed by the physician during the facility's normal $30.00 business hours. A PPD-TB screen will be performed with the new hire Firefighter physical. HEPATITIS A When requested, a Hepatitis A inoculation will be scheduled and performed by the physician during the N/A facility's normal business hours. HEPATITIS B When requested, a Hepatitis B inoculation(s) will be scheduled and N/A performed by the physician during the facility's normal business hours. TYPHOID When requested, a Typhoid inoculation will be scheduled and performed by the physician during the facility's normal N/A business hours. TETANUS When requested, a Tetanus inoculation will be scheduled and performed by the Combined physician during the facility's normal with business hours. Diphtheria below: DIPHTHERIA When requested, a Diphtheria inoculation will be scheduled and N/A performed by the physician during the facility's normal business hours. DOT PHYSICAL: When requested, a DOT physical will (SEE ATTACHMENT be scheduled and performed by the "B" to be completed by physician during the facility's normal $95.00 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 physical. Thereafter, only a DOT physical is performed by the physician. Physician may also perform a urine drug screen if requested separately by 14 Monroe County BOCC. POST -OFFER When requested, a post -offer physical PHYSICAL: will be scheduled and performed by the $70.00 (SEE ATTACHMENT physician during the facility's normal "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. FIREFIGHTER When requested, Firefighter physical PHYSICAL (SEE will be scheduled and performed by the ATTACHMENTS "E" to physician during the facility's normal $75.00 be completed by employee business hours. Includes exam and *Fee Also and physician). physician review of employee health includes history and job description. Respirator Physician may also perform a urine Physical at drug screen if requested separately by no additional Monroe County BOCC. charge. Also required: EKG, Chest X-ray, Spiiometry, Hearing/Audiogram, Stress Test, PPD-TB screen. FITNESS FOR DUTY When requested, a Fitness for Duty $70.00 PHYSICAL (SEE Physical may be requested at any time ATTACHMENT "A" to be by the employer in the employee's 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 *$80 PHYSICAL, (SEE will be scheduled and performed by the ATTACHMENTS "C" physician during the facility's normal 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 Sprirometry. *See Firefighter Physical EKG Normally done in conjunction with the $80.00 Firefighter physical. 15 CHEST X RAY Chest X Ray is normally done in Physician conjunction with the New Hire provides Firefighter and Respirator physical if order to Key there is an issue with the EKG or West spirometry results. Diagnostics. Key West Diagnostics bills County directly ($75.00) SPIROMETRY Normally done in conjunction with the Respirator physical. All Firefighters and employees who use a respirator will 520.00 have a Spirometry when hired. Normally done in conjunction with the HEARING/AUDIOGRAM appropriate physical. May be requested 530.00 separately by Monroe County BOCC. STRESS TEST (SEE Normally done in conjunction with the Physician ATTACHMENT "D" for new hire Firefighter physical. provides explanation of services to Performed thereafter for firefighters as order to Dr. be performed by needed. Boros. Dr. physician) Boros schedules test with Firefighter. Boros provides results and bill ($200) to HR with copy of results to Samess. Samess sends results via fax to HR. CHEMICAL Tests Glucose (sugar), kidneys, liver (1 Fee included PANEL/CMP tube of blood drawn). in Firefighter Normally done in conjunction with the physical Firefighter Physical. CBC Test to see if Anemic; if any infections Fee included within the body; if dehydrated (test in Firefighter from 1 of the tubes of blood drawn). physical Normally done in conjunction with the Firefighter Physical. LIPIDS Tests good cholesterol and bad 555.00 (CHOLESTEROL) cholesterol ( one of the tubes of blood drawn) Normally done in conjunction with the 16 Firefighter Physical. UA DIP Normally done in conjunction with the *Included in DOT physical physical fee UA WITH MICRO Normally done in conjunction with the *Included in Firefighter Physical physical fee 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 ONE: COUNTY FORMS AND INSURANCE FORMS LOBBYING AND CONFLICT OF INTEREST CLAUSE SWORN STATEMENT UNDER ORDINANCE NO. 010-1990 MONROE COUNTY, FLORIDA ETHICS CLAUSE "RONALD R. SAMESS, M.D." (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." (Signature) Date: STATE OF: 4I066k COUNTY OF: Al.(',11 L Subscribed and sworn to (or affirmed) before me on ffl"6A [I (date) by_�I�• 1" l �• (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission ' °�¢'•,, Notary Public - State of Florida * c My CortrNaeion Expres Now 27.2011 )g - s;. Z� Commission # 00 T37309 �'!�,°f ; �d;•�` Bonded.Thfv* Now"W Notary Assn. NON -COLLUSION AFFIDAVIT I, of the city of my oath, and under penalty of perjury, depose and say that according to law on 1. 1 am of the firm of the bidder making the Proposal for the project described in the Request for Proposals for 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) 1 Date: STATE OF:ie6k COUNTY OF: M U�°"L Subscribed and sworn to (or affirmed) before me on awl (date) by _ �(� ,� - �- �,� (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLICPAM My Commission Expi $p``'�r P`A�%'': Notary P bfcU S atte oiFlorida • ; , My Commis on xpires Nov 27.2011 19 _ commission # DD 737309 °'% OF ;,`,•�� Bonded Through National Notary Assn. DRUG -FREE WORKPLACE FORM The undersigned vendor in accordance with Florida Statutes Section 287.087 hereby certifies that: RONALD R. SAMESS, M.D. (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 nolo 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. (Signature) \ Date:1��\�\ STATE OF:-*D6&a_ COUNTY OF: `�� 1mat Subscribed and sworn to (or affirmed) before me on J1 I (date) by �6wjd, I �J • �� (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. PL l ffiw NOTARY PUBLIC My Commission Expires: AMELA . PUM R' AMELA L. PUMAR ?r*• *`4t Notary Public - State of Florida 20 - • r • My Commission Expires Nov 27, 2011 Commission # DID737309 Bonded Through National Notary Assn. 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 Ronald R. Samess, M.D. (Contractor's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. i (Signature) Date: STATE OF:��Q�� COUNTY OF: Subscribed and sworn to (or affirmed) before me on o)4 I (date) by _ ��- (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 21 PAMELA L. PUMAR Notary Public - State of Florida • 3 My Commission Expires Nov 27, 2011 Commission # DD 737309 Banded Through National Notary Assn 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 RONALD R. SAMESS, M.D. 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 RONALD R. SAMESS, M.D. 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 Imts $ 100,000 Bodily Inj. 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 EMPLOYMENT PHYSICAL SERVICES ArlACHMENT A ATTACHED SHEETS' u rile yr c�.vm MEDICAL RECORD REPORT OF MEDICAL HISTORY 111 0-TEiThis in ormatl'an is for official and m aily-confidentia use only and will not be released to unauthorized persons 1 NAME OF PATIENT rLost. first, rn,ddle) 2 IDENTIFICATION NUMBER 7 -Position 4a. HOME STREET ADDRESS 6treer or RFD, City or Town. State, and ZIP Codel 5 EXAMINING FACILITY an CITV c STATE ,ad. ZIP CODE 3 PURPOSE OF EXAMINAf 7 STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages,! necessary) a. PRESENT HEALTH In. CURRENT MEDICATION REGULAR OR INTERM. c. ALLERGfES flndude insect Diresistings and common foods) --- —�----------d. HEIGHT le. WEIGHT- 8 PATIENT'S OCCl1PA LION -------------- ec one— Ej RIGHT HANDED LEFT HANDED 10. PAS T/CUHHLN T MhUICAL HIS I UKY CHECK EACH OEM YES NO DON'T KNOW CHECK EACH ITEM YES NO DON'T KNOW CHECK EACH ITEM YES NO DON'T KNOW Household contact with anyone with tuberculosis Shortness of breath Bone, joint or other deformity Pain of pressure in chest Loss of finger or toe Tuberculosis or positive TB last Chronic cough I P.ilnful or "trick' shoulder or elbow Blood ,n sputum or when coughing Palpitation or pounding heart Heart trouble Recurrent back pain or any back injury Excessive bleeding alter injury or dental work High or low blood pressure Cramps ,n your legs "Trick" or locked knee Suicide attempt or plans Frequent indigestion Foot trouble Sleepwalking Stomach, jiver or intestinal trouble Nerve injury Wear corrective lenses GoII bladder trouble or gallstones Paralysis fincluding infantile) Eye surgery to Correct vision Epilepsy or seizure Lack vision in either eye Jaundice or hepatitis Car, train, sea or air sickness Wear a hearing aid Broken bones Frequent trouble sleeping Stutter or stammer Adverse reaction to modication Depression or excessive worry Wear a brace or back support Skin diseases Loss of memory of amnesia Scarlet fever Rheumatic fever Tumor. growth, cyst. cancer Hemla Nervous trouble of any sort Periods of unconsciousness Swollen or painful joints I Hemorrhoids or rectal disease Parantlsibling with diabetes. cancer, stroke or heart disease Frequent or severe headaches Frequent or painful urination Dizziness or fainting spells Bed wetting since age 12 Xray or other radiation therapy I Eye trouble Hearing toss Kidney stone or blood in urine Sugar or albumin in urine Chemotherapy Asbestos or toxic shem,cai exposure —� Recur,ent ear infections Chronic or frequent rolds Severe tooth or gom trouble ----- Sinusitis feverf Hay or allergic. rhm,tr9 Head injury Asthma - --- --i —1 Sexually transmitted diseases j Recent gain or joss of weight f Eating disorder lanoreria buhmiaz c 1 AetrthrOis. Rheumatism . or Bursitis —� I Plate. pin or rod ,n any bone Easy fuvgab,hty -- Been told to cut down or tic criticized for alcohrrl use Used illegal dl substances Used tobacco I Thyroidtrouble or goiter N5N 1740 UU-1b1 0l61:1 Previous edition not usatlle J I H/YVNnLP rvrtvi 7J '.Htv to `Jbl Prescribed by ICMH/GSA FIRMR 141 CFRI 101 9 .02 1 11 . FEMALES ONLY —" DON'T (DATE OF LAST MENSTRUAL DAT£ OF LAST PAP SMEAR DATE OF LAST MAMMO CHECK EACH ITEM YES NO KNOW (PERIOD I !GRAM Treated for a female disorder N/ N/A N/A Change in menstrual pattern CHECK EACH ITEM. IF -Y£,, EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER. ITEM -- _ YES '�, NO 1 2. Have you been refused employment or been unable to hold a lob or'�, stay in school because of: a. Sensitivity to chemicals, dust, sunlight, etc. b Inability to perform certain motions. c. Inability to assume certain posRions. d.Other medical reasons (N yes, give reasons.) 1 3. Have you ever been treated for a mental condition? (it yes, specify when, where, and give deteds.l 14 Have you ever been denied life insurance? (it yea, stars reason and give details) 15 Have you had. or have you been advised to have, any operation. Ilf yes, describe and give age at which occurred.! 16 Have you ever been a patient in any type of hosptap fir 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, or other practitioners within the past 5 years for other than minor and rllnessesr (If yes, give complete address of doctor, pit derails.) 1 B. Have you ever been rejected for military service because of physical, mental, or other reasons? Of yes, give date and reason for rejection,? 1 9. Have you ever been discharged from military service because of physical, mental, or other reasonsi fif yes, give date, reason, and type of discharge, whether honorable, other then honorable, for unfitness or unsuitability.) 20. Have you ever receWed, is there pending, or have you ever applied for pension or compensation for axisling cysabitity? (lf yes, specify what kind, granted by whom, and what amount, when, why.) 22. Have you ever been diagnosed with a learning disability? Rf yes, give type, where, and how diagnosed.) N/A cent y t at gave rev�ewa t e oregoing in ormation sup re by me and that it is true aria compete to Ul a est o my now a ge. aut ooze any of the doctors, hospitals, or c4 nres 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 tine andior imprisonment. 24a. TYPED OR PRINTED NAME OF EXAMINEE 24b. SIGNATURE 24c. 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 shell comment on all positive answers in Items 7 through 11, Physician may develop by interview any additional medical history deemed important, and record any s,gndreiant findings here.! Z6a iVPED OR PRIN IED NAME OF PHYSICIAN OR EXADA INER 26b. SIGNATURE I26c DA STANDARD FORM 93 IREV 6-98) BACK i MEDICAL RECORD REPORT OF MEDICAL EXAMINATION 2 IDENTIFICATION NUMBER 3 position 1 LAST NAME-- FIRST NAME MIDDLE NAME —.l.v.�—"--cnn�RESS (Nu —fiber. s<Ref or RFD, cNy a town. slafaand ZIP Crde) 5. EMERGENCY (Name and addmss orcontad) 8. SEX 6. DATE OF BIRTH �7AGE FEMALE F7 MALE t t. RACE 10 PLACE OF BIRTH W1ITE BLACK 12b, ORGANIZATION UNIT 12a.AGENCY (Check each item In approprtate OOlumn. enter "NE' R not eve nl A. HEAD. FACE. NECK AND SCALP B EARS -GENE (INTERN(A ry etc ny under Rem, 39 and 40) C. DRUMS (Perforation) D NOSE E. SINUSES F. MOUTH AND THROAT G EYES - GENERAL (Mewl acuity ecd -ftx1100 urder item+ 28. 29, and 36) H OPTHALMOSCOPIC I. PUPILS (Equality andrewtbn) J. OCULAR MOTILITY (ASSnclated Parallel movements nysfegmus) K. LUNGS AND CHEST L. HEART (Thrust, s12e, rhythm. sounds) M. VASCULAR SYSTEM (Varicoa+fVs, etc.) N ABDOMEN AND VISCERA (Includehemia) N m number b OTE S. (Describe every abnomlalNy /n detaH. Emer pertinent Re 9. RELATIONSHIP OF CONTACT xg AMERICAN INOIAW HISPANIC HISPANIC ASIANIPACIFIC ALASKA NATIVE Fj YJFIITE BLACK ISLANDER 13. TOTAL YEARS GOVERNMENT SERVICE a. MILITARY b. CIVILIAN 15. RATING OR SPECIALTY OF EXAMINER 16 PURPOSE OF EXAMINATION l (Check each item In epPropnate column, enter 'NE' A not evaluated) O. PROSTATE (0ver40orcNnkelfy/ndlc8ted) p. TESTICULAR R. ENDOCRINE SYSTEM S. G.0 SYSTEM T. UPPER EXTREMITIES (Strength, rangeof motion) U. FEET V. LOWER EXTREMITIES (Except r—n ISreength, range ofmotion) W. SPINE, OTHER MUSCULOSKELETAL X. IDENTIFYING BODY MARKS, SCARS, TATTOOS Y. SKIN, LYMPHATICS Z. NEUROLOGI C (Equl/bdum tests udder tam 41) AA. PSYCHIATRIC (SpecNyany peraon—tydeviatlon) I 1 comment Continue 1n item 42 and use ackiftnal sheets Nnec>dssary. 8DENTAL (Place apP�opr'.ale syrnbds, shown In examples. above or bebw number upper and paver taeur.r -x—� F,xed 1. p 1 Nan resw"bb Replaced X Missing / I 9 by 1 30 Teeth 's —� Dentures 1.� ( x 1 Parnal De Mures 1Y(�Restorable '44 ` rein 3 reels X x x 0 L R 2 3 4 5 6 7 a 9 t0 11 1Z 19 14 21 20 19 15 t6 18 17 F I 1 G 3�-30 29 2t! 27 26 ZS 24 23 22 T H 19. TEST RESUUS N-oPtea A URINALYSIS (1) SPECIFIC GRAVITY (4) MICROSCOPIC /� (2) URINE ALBUMIN , _ N (Pt (3) URINE SUGAR E BLOOD TYPE A C SYPHILIS SEROLOGY (SpecAyl`lAestused D. EKGA FACTOR ant reserll,J � 1 u � t' 1 ' a&t26 ^, gd "Ing Per7orm Prc War-`✓DIOR nn 97 DEFECTS AND DISEASES of results are preferred as attachments( TOTHE�RTESTS CHESTX-RAY OR P:0-::"Mm number and result) ND RH ( I STANDARD FORM 98 (Rea 10-94) (EG) Prasr t,bed by GSAACMR FIRMR (41 CFR) 201.9 202-1 NAML MEASUREMENTS AND NO OF SHEETS ATTACHED 2U HEIGHT WEIGHT. COLOR HAIR 23. COLOR EYES 24 BUILD _ F21 25 TEMPERATURE SLENDER MEDIUM HEAW OBESE 26 BLOODet ert H�ef) _ 27. PULS E (Arm at heed oum.1) A RSTANDING SYS A. SITT NG B RECUMBENT C STAN ING D. AFTER EkERCISE E- 2 MINS AFTER ING DIAS (Stuns.) pIAS26 (3mils) DISTANT 29. REFRACON 30 NEAR VISION RIGtJT 20 COBY S CX CORR TO BY LEFT 20/ GCBY S CX 31 HETEROPHORIA,SoecAyJataikw1 it CORR TO BY ESO ENO ►. ► 1 R H. LH PRISM DIV PRISM CONV PC PD CT DATION 33 COLOR VISION (Testuwd androsutp 34. DEPTH PERCEPTIONUNCORRECTED (Test usedandsaore)01aCORRECTED =RIGHTLEFT VISION 36NIGHTVISION(Testuwdandsccre) 37,REOLENSTES1-f� 38.INTRA0CULARTENSION FT RIGHT LEFTING 40 AUDIOMETER 41 PSYCHOLOGICAL AND PSYCHOMOTOR (TcsfsusWand scom) RIGHT WN 15SV ;15 210 000 258 28981 4000 6M 9192 �A t LEFTIN/V /15SV f15 RIGH T LEFT 42. NOTES (Continue I) AND SIGNIFICANT OR INTERVAL HISTORY (Use adILWonai &beets J ne:essary) 43 SUMMARY OF DEFECTS AND DIAGNOSES (Listdiagnoseswltttltemnumbers) 44 RECOMMENDATIONS • FURTHER SPEOAUST EXAMINATIONS INDICATED (Spe,:lly) 45A. PHYSICAL PPrFu F 46. EXAMINEE (Cheri) A 0 IS QUALIFIED FOR =PHYSICAL In accordance with B IS NOTQUALIFIEOFOR attached job descri tion 47IF NOT QUALIFIED, LIST DISWAUF/ING DEFECTS BY ITEM NUMBER B C E 48. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE SIGNATURE SIGNATURE —' 49 TYPED OR PRINTED NAME OF PHYSICIAN 50 TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (/ndk:ate witch) 51 TYPED OR PRINTED NAME 0FPEVIE.WNG OFFICER OR APPROVING AUTHORI SIGNATURE a-mmum Ku ruKM tl8 (Rer 10.941 SACK EMPi OYMENT PHYSICAL SERVICES ATTACHMENT B 3 C Q C. A (� p^1 w Om :3 (n wx 3 C � n� w O p .: 3 (o � o J_ 7 (D �o 3w Q w a O J N �=r mw a �. (D OL ,n DOi x Q ?. cyi (D C y3 (o (D (D j Q Q Aa 30 CD c J m ar 5F ar O 5 CD n m i (D CA J C CD v w m X A 0) (D (D cy W O (D CCD 5 a 3 w 0 J O 3 -v 5 (D w J a a (D m R w J a Err w A c m Di (n (D O �n o� J 3 J N a w m C (D X w 3 J O J w n 3 m n 0 W 3 p o❑❑ [:]DO ❑❑❑ m N _ _—____� D _ o y • CL 1 � y N rn = S L� r m m L cn S> to m q� �3 ) N d C w (n J �' Qg c fn �i .v�i H n 2f $ S' an d bo' w 4 I m ai r. ` m s �_ 0 `� @ � q A �_. N m Gov m� T • �G 60i 3" m CE m g o m ' ... o m x - � rb �� 0 n CD ti OL-- �w QD 8 v a S v m CD N w (D n O N m 8 4 > fV O 3 w CD j cn n <D Q. 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M W am CL 33 7 2 A vo m m s- 7 -5 h 0 9 "9; _a 01 j Z N O' N (D < C O d C 2 7 0 m g p3iCl D m O� '3 mp�m'<m 33 N d C yyvg 7 �N'� O G 7 7 3 a.d 3, (D 7' (O a �' 01 y 3 ;oyN3. a 3�C 7 3 n H m FMDL(DYMENT PHYSICAL SERVICES ATTACHMENT C )irator Medical Evaluation Questioru�,air Co the employer. Answers to questions in Set Lion 1. and to L111-Aion 4 in S�t lion 2 of Part A, do not require a medic al —(amiIwtion. ho the employee: Can you read? (t Nx t k one): ....... .................... ................ .............................. ......... ............ J Yes J No our employer must allow you to answer this questionnaire dunng normal working hours, or at a time and I+la(e that is t t)m vnwnt to you. To maintain your t onfidentiahty, 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 health rare professional who will review it. the following information must he pnwided by Query empluyar who has lx rn sr let ted to use any type of respirator (pleaw print). Name: Age (to nearest year): Height: feet , inches Weight; ._ Ibs. Phone number where you can be reached by the health care person who reviews this (include area code): _ The best time to call you at this number. Has your employer told you how to contact the health earn person who will review this (check one): U Yes ❑ No job 'Title: Sex (che(k one) U tiluje U Female Date: Check the type of respirator you will use (you ran Cher k more than one category): a. ❑ N, R, or P disposable respirator (filter -mask, non -cartridge type only). a. U Other type (fir example, half- or full-facepiece type, powered -air purifying, supplied -air, self-contained breathing apparatus). Have you wom a respirator. U Yt-s U No If "yes," what type(s): Part A — Section 2 (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please check "yes" or "no" ). I. Do you currently smoke tobacco, or have you smoked tobacco in the last month? ................................... U Yes U No 2 Have you ever had any of the following conditions? a. Seizures (fits): .................................................................................................................................................. U Yes U No b. Diabetes (sugar disease):................................................................................................................................ U Yes ❑ No c. Allergic reactions that interfere with breathing: ........................................ ................................................ d. Claustrophobia (fear of closed -in plac(s):......................................................................... U Yes U No . U Yes ❑ No V. Trouble smelling odors: ......................................................................................................................... 3. Have you ever had any of the following pulmonary or lung problems? 'J Yes J No a. Asbestosis::............................................................................................ .......................................... h. Asthma: ............................... . .... J Yes J No ............................................................................................................... ......... U Yes a No C. Chrome bronchitis :...................................... ........... ... ......................................................................... d. Fmphys4-ma:........................................................................ .............J Yt-, 'J No e. Pixmumonia:................................................................................. ...... U Yes J Diu f. Tuht-nulnsis:......................................................_.............. .............................. U Yes J No ........................................................... };. slh(wos: _........ JYiw J:�'o h. f'neumotlu»rax (tollalst'd lung): ............... ....................................................................................... L I.un}; c ant er:..............................._... ...... J Yes 'J No ................................. ........................ I. liroken ribs: ............................ J Yes , 10 .......... ....... -- . . k. \m, t hest injuriv%or suryent-;: ........... _...... J Yet J No ............................... I. \nv ,,th,-r lent; problem that tou'w la�e-n told alv iit: _.. .......... ]Yew _] .\u .......... J Yew J :N cncusce i Mr -A lust 35M.1 Dale PMy 8. 2OW 4. Do you currently hdve any of the following symptoms of pulmon.uy or lung illness? J. Shortness; of breath: ...................................................... ................................................................ ................ J Yes J No h, chortness of breath when w.ilkulg fast on level ground or walking up a %light hill or int ling:.......... J Yes J No . Shortness of breath when walking, with other pt-()pleat an ordinary pace on level ground :.............') Yeti !J No d. I iave to Slop for breath when walking at your uwn pate on level ground: .............. ...... - .................... J Yes J No e. Shortness of breath when washing or dressing your k4f:.......................................................................... J Yes J No f. Shortness of breath that interferes with your job.... ............................................... .................................. J Yes JNo };. Cou),,hing that produces phlegm (this k sputum): ..................................................................................... J Yes J No h. Coughing that wakes you early in the morning: .......................................................................... .............. !J Yes J No i. Coughing that occurs mostly when you are lying down: ........................................................................ J Yes J No j. Coughing up blot)d in the last month: ......................................................................................................... .. J Yes J No k. 4� htti ling ........................................ D Yes J No res th your lob ...................................... !J Yes J No m. Chest pun when you breathe deeply: ....................................................................................................... f] Yes 0 No n. ,any other symptoms that you think may he related to lung problems: ................................................ J Yes J No 5. Have you ever had any of the following cardiovascular orheart problems? a. Heartattack:.................................................................................................................................................... J Yes J No b. Stroke: ............................................................................................................................................................... J Yes J No C. Anginu:............................................................................................................................................................. ❑Yes J No d. Heart failure: ........................................................................................................................... J Yes ❑ No ........................ e. Swelling in your legs or feet (n)t caused by walking): ........... .......................................... J Yes 0 No ........................ f. Heart arrhythmia (heart beating irregularly): ............................................................................................. J Yes ❑ No g. High blood pressure: .............................................................................................................❑ Yes J No ....................... . h. Any other heart problem that you've been told about: .......................... J Yes ❑ No .................................................. 6. Have you ever had any of the following cardiovascular or heart symptoms? a. Frequent pain or tightness in your chest: .................................................................................................... J Yes J No b. Pain or tightness in your chest during physical activity: .......................................................................... J Yes ❑ No C. Pain or tightness in your chest that interferes with your job: ............................................................. J Yes ❑ No d. In the past two years, have you noticed your heart skipping or missing a beat: ................................... J Yes ❑ No e. Heartburn or indigestion that is not related to eating :........................ ............... J Yes ❑ No ........................................ f. Any other symptoms that you think may he related to heart or circulation problems: ...................... J Yes J No 7. Do you currently take medication for any of the following problems? a. Breathing; or lung problems: .......................................................................................................................... J Yes ❑ No b. Heart trouble: ........................................................................... ............. U Yes J No .................. ........................................ c. Blood pn•s ure:............................................................................... J Yes J No ................................................................ d. Seizures (fits): ............................................. ............................................. . ........... J Yes J No ........................................... S. If you've used a respirator, have you ever had any of the following problems? (If t•ou've never used a respirator go to (luestion 9) a. Eve irritation:............................................................................................................................. ............':a Yew J No h. Skin allergies or rashes: .... .............. ................................... J Yt's J No .................................... t. lrtxioty:............................. ...................... .......................................................................... J Yes �J No d. l ;etter.il teeak,x ss ur (.idly;ue:.................................... ........... ... J 1't's J No .......................................................... .... r. Other proklem that uiterferos t%,th your respirator UIW:...... _..... ........................ ....... J 1 rs J No Ercbsue 3 "ACA k-A aeM, t D* May 8. 20M 9. would you like to talk to the health care professional who will review this questionnaire about your .I ILsvvers to this yuestiunnoire:...................................................................................................................................... 'J Yo.; ..1 No Qu(wtionLs 11) to 13 below must lw answered by every employ(4- who, has Nvn swlty ted to use either a f011-6opicto respirator or a scif o ontained breathing apparatus (SCBA). For emplo%ees who have Nx,n selcvted to use other t% pes of respirators, arLswerrng those questions is voluntary. 10. have you ever lost vision in either eye (temporarily or permanently):....................................................... J Yc-,- J No It. Do you currently have any of the following vision problems? a. Wcar contatt lenses: ........................................................................................................................................ J YesQ No b. Wear t;lasses:.................................................................................................................................................... J Yes `> No c. Color blind: ....................................................................................................................................................... ❑ Yes ❑ No d. Other eye or vision problem: ......................................................................................................................... ❑ Yes ❑ No 12. Have you ever had an injury to your ears, including a broken ear drum:.......... ......................................... 0 Yes ❑ No 13. Do you currently have any of the following hearing problems? a. Difficulty hearing: ........................................................................................................................................... 0 Yes 0 No b. Wear a hearing aid: ......................................................................................................................................... 0 Yes 0 No C. Any other hearing or ear problem: ............................................................................................................... 0 Yes ❑ No 14. Have you ever had a back injury:........................................................................................................................ ❑ Yes ❑ No 15. Do you currently have any of the following musculoskeletal problems? a. Weakness in any of your arms, hands, legs, or feet: .................................................................................. 0 Yes ❑ No b. Back pain:.......................................................................................................................................................... 0 Yes 0 No C. Difficulty fully moving your arms and legs: .............................................................................................. 0 Yes 0 No d. Pain or stiffness when you lean forward or backward at the waist: ....................................................... ❑ Yes ❑ No e. Difficulty fully moving your head up or down: ........................................................................................ ❑ Yes ❑ No f. Difficulty fully moving your head side to side: ......................................................................................... ❑ Yes 0 No g. Difficulty bending at your knees:.................................................................................................................. 0 Yes ❑ No h. Difficulty squatting to the ground:.............................................................................................................. 0 Yes ❑ No i. Climbing a flight of stairs or a ladder carrying more than 25 Ibs.:........................................................... 0 Yes 0 No j. Any other muscle or skeletal problem that interferes with using a respirator: ...................................... J Yes 0 No Part B ,any of the following questions, and other questions rn,t listed, may be added to the questionnaire at the disc retion of the health (are professional who w ill review the questionnaire. 1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxyg) en: ................................... I .................... .................... .......J Yes J No ........................................... or others} rnptortrs when you're working under these (onditions:................_................................_............._.....'J Yes 'J No 2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (c' )y1 .,so 4 hnnes, or dUst), or h<,ve you come into .kin t onta, t %%ith ho/ard,urs , ho'nIft-AIs :.........................._. J ies J No Name Home Address Telephone Length of Employment RESPIRATOR USE PHYSICAL Age Sex Occupation I agree to the release of this information for State and Federal regulatory purposes to the extent provided by applicable laws. DATE EMPLOYER SIGNED ❑ Follow-up Medical Evaluation Physical Required. (Positive response — Question 1-8). ❑ Post -Offer Physical: Medical Evaluation Physical Required. 9. Would you like to talk to the health cam professional who will review this questionnaire about your amswers to this questionnairy:.............. Questions Mo 15 below must be answered by every employ n spirator or *r whu has been selected to use either a full-farepietic a self. urttainevl bn athinl; apparatus (SCBA). For employees who have been selected to use other tvpcs of nwpiratom, answering tht questionss Ls voluntary. 10. Have you ever lost vision in either eye (temporarily orperaLmently)• ....................... 11. Do you currently have any of the following vision problems? a. Wvar Contact lenses: ....... ernes:................. ...................................... h. Wear glasses :............. ........ 0 Yes 0 Nu ................................. ................................... O Yes O No i. Color blind: ........................ ..................................................................................................................................... 0 Yes ❑ No d. Other eye or vision problem: """""""........................................ ...................................... 12 Have you ever had an injury to your ears, including a broken ear drum:........................................................ 13. Do you currently have any of the following hearing problems? a. Difficulty hearing: .............................................................................................................................................0 Yes O No b. Wear a hearing aid: .................................................................. ............ .......................................................... ...0 Yes 0 No C. Any other hearing or ear problem..................................................................................................................0 Yes O No 14. Have you ever had a back injury: ...........................................................................................................................0 Yes ❑ No 15- Do you currently have any of the following musculoskeletal problems? a. Weakness in any of your arms, hands, legs, or feet :.............. b. Back ................................................. ...........❑Yes ❑ No pain: ................................................... ❑Yes O No C. Difficulty fully moving your arms and le ......................... legs: ❑Yes ❑ No d. Pain or stiffness when you lean forward or backward at the waist.......................................................................... e. Difficulty fully moving your head up or down .................... 0 Yes ❑ No .............................................................. ❑Yes O No f. Difficulty fully movie ......... S Your head side to side: ...............................0 Yes O No g. Difficulty bending at your knees:............................................................................................... 0 Yes O No h. Difficulty squatting to the and. ..................... '................................ ....................0 Yes i. Climbing a flight of stairs or a ladder .................. Q No carrying more than 251bs.:...............................................................0 Yes O No j. Any other muscle orskeletal problem that interferes with using a respirator ................. ..........................0 Yes O No Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire. 1. in your present job, are you working at high altitudes (over5AW feet) or in a place that has lower than normal amounts of oxygen .................... ....................................................................... or other symptoms when you're working under these conditions: ❑Yes ❑ No................. 0 Yes O No 2 At work orat home, have you ever been exposed to hazardous solvents, hazardous airborne chemyray (e-& des, fumes, or dust), or have you come into skin contact with hazardous chemicals: ..............................0 Yes ❑ No NICV.last .14U (Xa.IIV 7q) I have you everworiced with any of the materials, or under any of the conditions, listed below: a. Ashootos:.................................................................................................... h. Siliia (e.t;. insandbUsting):.......... ........................................................!J Yes .............................................................................. D No �. un},sten/,-obalt (e.g. gTindingor ................................. .....'� Yes welding this niaterial):.............. `� Nu .................. ...''J Yes D No ,-aluminum:................................. ....................................................................... .... ................OYs 'JNo f. C0al (for t-xample, minil,g):............. ...................................................................................................... J Yes J No ............... 'J YIs h. Tin:- .... ...................... .. ...'J Yes 0 �o i. ustyenvin)nnuents:............................... .............................................................................. .... J Yes .............. �J Nu j. Other hazardous exposures: .............................. . ....... ..................................... ............................................................`J Yes 0 No lf"yes," descrihe� these ..0 ................................. .. Yes ..................................... 0 No -exposures: 4. Listany second jobs onside businesses you have- 5. List yourprevious occupations: 6. Listyourcurrentand previous hobbies: 7. Have you been in the military services? ..................................................................................................................0 Yes D No If "yes," were you exposed to biological or chemical agents (either in training or combat): .................................. Q Yes O No S. Have you ever worked on a HAZ 1AT team? ............. ..............................................................................❑ Yes O No 9.Other than medications for breathing and lung problems, heart double, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications): ....................................................................................................................0 Yes 0 No If "yes," name the medications if you know them: 10. Will you be using any of the following items with your respirator (s)? a. HEPA Filters:b. Canisters (fur example, gasmasks):.......... ................................................ Q Yes .................................... No c. Cartridges: ..................................... ........................................................ ...0 Yes 0 No .......................................................................... 11. How often are you expected to use the mspirator(sp: a. Escape only (no rescue) :..................... ............................................... b. Emergency rescue only......................... El Yes 0 No................................................ c. Less than 5 hours per week........................................... ............................................. .............. 0 Yes 0 No d. Less than 2 hours per day: .................... .............................................. 0 YES ...................................................•........................................................0 O NO 2 to 4 lours per day.................................................................. Yes 0 Noe. f. Over 4 lours per day: D Yes 0 No................................................ ..................................................... 0 Yes 0 No -Ntc.e firs. - 8013 R* RVIZ(x) 12. During the period you a1v using the L.spirato4s), is yourwork effort a. Light (l(r;s than ?tll) k,al per hour): .................... If ""y, s," how long; doc s this pen()d last during the average shift: hrs.— mires. Examples of a light work effort are sitting; while writings typing; drafting, or performing lig;imt a5u,mhly work or standing v,dole op,: rating; a drill press (1-3 lbs.) or controlling mak-hints. b. %fOderate (2(X) to 50load per hour):................. ........................................ ........0 Yes ............ .................................. If ti'c s,' how long, dens this pericxl last during the average 5Imi1IL: hrs._ mite. Examples of moderate work effort arc sitting; while nailing, or fthrW driving; a truck or bus in urban tra(fi(; standing; while drilling;, nailing, performing; assembly work, or transferring a moderate load (alx)ut .35 lbs.) at trunk level; walking; on a level surface iboUt 2 mph or down a 3-del ee grade ahmut 3 mph; or pushing a whet,lbarrow with a heavy load (about 1U) lbs.) on a level surface. J Rio N'o C. Heavy (ahove -13) kcal per hour): ............................................... .................... ....................:..... It -Yes," how long dues this period last during the average shift hrs._ mire.0 Yes ❑ No s. Examples of heavy work are lifting a heavy load (about 30 lbs.) from the floor to your waist or shoulder; working; on a loading dock; shovelingy standing; while bricklaying or chipping; castings; walkumg up an 8-degree grade about 2 mph; climbing; stairs with a heavy load (about 30 lbs.). 13. VVM you be wearing protective clothing and/or equipment (other than the respirato:j when you're usingyour resp irator....................... ............................................................................................................................... If „yes,,' describe this protective clothing and/or equipment ❑Yes ❑ No 14. Will you be working under hot conditions (temperature exceeding 7" IMF:....................................................0 Yes ❑ No 15. Will you be working under humid conditions: ...................................................................................................0 Yes ❑ No 17. Describe any special or hazardous conditions you might encounter when you're using your respirators) (for example, confined spaces, life -threatening gasesk A Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s): Name of the first toxic substance: Estimated maximum exposure level per shift Ntca treiL- 4013 arc Im2 M Duration of -<Fx>sure pershift: Name of the Second toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift Name of the third toxa: substance: Estimated maximum exposure level per shift: Duration of exposure per shift The name of other toxic substances that you'll be exposed to while using your. respirator. 19. Descrfl�e any special responsObilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security; . mxpl wvI MCA trrt • W13 Dau,141,100 PLHCP Follow-U cniployee job Date of this follow-up: Reasons for follow-up Actions: Medical Examination Copy of recommendation given to employee? O Yes 0 No Reconimend,itions -,bout employee use of the nrspirutor: Limitations - [Need for follow-up medical evaluations - Date signed: Signed; Date given: RESPIRATOR USE PHYSICAL See Attached Job 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 1. HEIGHT WEIGHT 2. HEART: Murmers: Rate Rhythm Enlargement 3. LUNGS: Pulmonary Function Within Normal Limits Outside Normal Limits 4. PA CHEST X-RAY: Within Normal Limits Outside Normal Limits 5. 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 EMPLOYMEP•1T PHYSICAL SERVICES AT iACHMENT D yright C 2000 NFP.A, All Rights Reserved NFPA 1582 Standard on Medical Requirements for Fire Fighters and Information for Fire Department Physicians 2000 Edition This edition of NFPA 1582, Standard on Medical Requirements for Fire Fighters and Information for Fire 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, IA. 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 1582 A joint task force of members representing both the Technical Committees on Fire Service Occupational Safety and Health and Fire Fighter Professional Qualifications began address- ing medical requirements for fire fighters in blanch 1988. A standing subcommittee on Med- ical/Physical Requirements for Fire Fighters was created under the Fire Service Occupational Safety and Health Committee in 19% 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 Qualifications, 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 orcurrent fire fighter would prevent that person from perform- ing fire -fighting 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 membership at the I992 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 fighters. 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 A material that would prohibit an individual from being hired or to continue as a fire fighter. The com- 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 forms. 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 disorders, asthma, and therapeutic anti -coagulation. 1582_1 1582-2 N[EDlG� REQU[RE, IE,`1TS FOR FIRE FIGHTERS AND INFO"IATION FOR FIRE DEPARTMENT PHY icuLNS The 2000 edition of this standard reflects (1) the technical committee's recognition that medical technology is continually changing and (2) the committee's effort to incorporate 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 t department physician changes in the essential function(s) the fire department performs. Conversely, 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 members 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 committee has changed the title of the standard to NFPA 1582, Slandaard on Medical Riircire f menu for Frye Rightm and Information for Fire Departme?rt Physiciam. 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. 2000 Edltmn CO�tS[ITiEE PERSONNEL Technical Committee on Fire Service Occupational Medical and Health Murmy E. Loftin, Chair Virginia Beach Fire Dept, VA (U]. Rep. NFPA Fire Service Section David J. Barillo, U.S. Army tnst. of Surgical Research, TX (SE] Kimberly S. Sevin, BiaCare, Ml (SE] Paul "Shoo" Slake, City of Baytown Fire & Rescue Services. TX (E] Repp. industrial Emergency Response Working Group Mary S. Bogucki, Yale Univerziry. Cr (SEj Anthony L Clark, Kenton CountyAirport Board, OH (U] Thomas J. Cuff, Jr., Firemens Assn. of the State of New York. NY [U j Tammy DiAnda, Reno Fire Dept., NV (U] John F. Folan, Northside Medical Assoc., NY (SE] Richard D. Gerkin, Jr., Good Samaritan Hospital/Phoenix Fire Dept.. AZ [E] Juan Gonzalez, Medflex: The Exercise Science Inst., TX (RT] W. Larry Kenney, Penn State University, PA (RT] Rep. Lindy Jacobs & Assoc. Sandra Kirkwood, [as Vegas Fire Dept., NV (Ul Frank P. Mineo, New York City Fire Dept., NY [U] Gary L Neilson, Truckee Meadows Fire Protection District. NV (U] Rep. Fire DepL Safety Officers Assn. Alternates David W. Dodson, Loveland Fire Dept., CO [U] (AIL to G. L Neilson) Michael S. Gray, Virginia Beach Fire Dept., VA (Ul (AIL to M. E. Loftin) Stephen N. Foley, NFPA Staff Liaison Deborah L Pritchett, Lawrence Township Fire Dept., IN [L] Rep. Indianapolis Metropolitan Professional Fire Fighters Union Gordon M. Sachs, IOCAD Emergency Services Group. PA (SEj Rep. Fairfield Community Fire Co., Inc. Daniel G. Sarno, ENH - OMEGA, IL [SE] James Sewell, Seattle Fire Dept., WA [Lj Rep. [nt'l Assn. of Fire Chiefs Philip C. Stirdeburg, LaFarge Fire DepL, WI [L] Rep. Nat'l Volunteer Fire Council Robert M. Sttatman, West Metro Fire Protection District, CO (RT] Rep. Metropolitan State College of Denver Andy C. Teeter, Tulsa Fire Dept., OK [U] Rep. Int 1 Fire Service Training Assn. KathyTinios, Cooperative Personnel Services, CA [SE] Teresa Waon, Santa Ana College, CA [SEj Don N. Whittaker, Lockheed -Martin Idaho Technologies Co., ID (E] Decker Williams, Phoenix Fire Dept., AZ (E) Thomas R. Luby, New York City Fire DepL, NY (U] (AIL to F. P. Mineo) Brian V. Moore, Phoenix Fire Dept., AZ [E] (AIL to D. Williams) This list represenis the membership at the time the Committee was balloted on the final test ojthis edition. Since that time, changes in the membership may have occurred. A key to classifications it found at the back of the document. NOTE. Membership on a committee shall not in and of itselfconstitute an endorsement of the Association 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. 1582-3 2000 Edition 1582-4 SIEDICVL REQUIREMENTS FOR FIRE FIGHTERS,4vD INFOR.tit \TION FOR FIRE DEPARTMENT PUNSItCGs,NS Contents Chapter 1 Administration ..................... 1582- 5 1-1 Scope ............................... 1582- 5 1-2 Purpose ............................. 1582- 5 1-3 Implementation ...................... 1582- 5 14 Drfinitions ........................... 1582- 5 Chapter 2 Medical Process .................... 1582- 6 2.1 Medical Evaluation Process ............. 1582- 6 2-2 Fire Department Roles ................. 1582- 6 2.3 Preplacement Medical Evaluation........ 1582- 6 24 Periodic Medical Evaluation ............ 1582- 7 2-5 Retum-to-Duty Medical Evaluation ....... 1582- 7 2m6 Medical Evaluation Records, Results, Reporting, and Confidentiality .......... 1582- 7 Chapter 3 Category A and Category B Medical Conditions ................. 1582- 8 3-1 Medical Conditions Affecting Ability to Perform ........................... 1582- 8 3.2 Head and Neck ....................... 1582- 8 3-3 Eyes and Vision ....................... 1582- 8 3-1 Ears and Hearing ..................... 1582- 8 3-5 Dental .............................. 1582- 8 3.6 Nose, Oropharynx, Trachea, Esophagus, and Larynx .......................... 1582- 8 3-7 Lungs and Chest Wall .................. 1582- 9 3-8 Heart and Vascular System ............. 1582- 9 3-9 Abdominal Organs and Gastrointestinal System .............................. 1582- 9 3-10 Genitourinary System .................. 1582- 9 3.11 Spine, Scapulae, Ribs, and Sacroiliacjoincs ...................... 1582-10 3.12 Extremities .......................... 1582-10 3.13 Neurological Disorders ................ 1582-10 3.14 Skin ................................ 1582-10 3.15 Blood and Blood -Forming Organs ....... 1582-10 316 Endocrine and Metabolic Disorders...... 1582-10 3-17 Systemic Diseases and Miscellaneous Conditions ........................... 1582-10 20M Edition 3.18 Tumors and Malignant Diseases.......... 1582-10 3-19 Psychiatric Conditions .................. 1582-11 3-20 Chemicals, Drugs, and Medications....... 1582-11 Chapter 4 Infectious Disease Program ........... 1582-11 4.1 Infection Control Program .............. 1582-11 4-2 Exposure incidents .................... 1582-11 4.3 Tuberculosis ........................ ..1582-11 4-4 Immunizations ........................1582-11 Chapter 5 Incident Scene Rehabilitation and Medical Treatment ............. 1582-11 5-1 Incident Scene Rehabilitation ........... 1582-11 3-2 Incident Scene Safety and Health ........ 1582-11 5-3 Evaluation and Triage of Member Injuries ...................... 1582-11 5-4 Incident Scene Rehabilitation Tactical Level Management Component ............... 1582-11 Chapter 6 Referenced Publications .............. 1582-12 Appendix A Explanatory Material .............. 1582-12 Appendix B Information for Fire Department Physicians .......................1582-21 Appendix C Essential Structural Fire -Fighting Functions ........................1582-26 Appendix D Guide for Fire Department Administrators .................... 1582-26 Appendix E Sample Forms .................... 1582-33 Appendix F Referenced Publications ...........1582-33 Index.......................................1582—}8 ,W%11NISTit\ rf()N NFPA 1582 Standard on Medical Requirements for Fire Fighters and Information for Fire Department Physicians 2000 Edition NOTICE: An asterisk (') following the number or letter des- ignatwti a paragraph indicates that explanatory matenal on the paragraph can he found in :kppeodix A. information on referenced pnblicauons can be found in Chapter 6 and appendix F. Chapter 1 Administration 1-1 Scope. 1-1.1 This standard shall contain medical requirements for members, including hull -time or part-time employees and paid or unpaid volunteers. It also shall provide information for phy- sicians retarding other areas of fire department medicine, including infection control and fireground rehabilitation. 1-1_2 These requirements are applicable to public, governmen- tal, military, private, and industrial fire departmentorganizations providing rescue, fire suppression, emergency medical services, hazardous materials mitigation, special operations, and other emergency services. I-1.3 This standard shall not apply to industrial fire brigades that also can be known as emergency brigades, emergency response teams, fire teams, plant emergency organizations, or mine emergency response teams. 1-2 Purpose. I-2.1 The purpose of this standard shall be to specify mini- mum medical requirements for candidates and current mem- bers. It also shall provide other information regarding fire department activities that assist the department physician in providing proper medical support for members. 1-2.2' The implementation of the medical requirements out - Mined in this standard shall help ensure that candidates and current members are medically capable of performing their required duties and shall help to reduce the risk of occupa- tional injuries and illnesses. 1-2.3 Nothing herein shall be intended to restrict anyjurisdic- tion from exceeding these minimum requirements. 1-3 Implementation. 1-3.1 For candidates, the medical requirements of this stan- dard shall be implemented when this standard is adopted by an authority having jurisdiction, on an effective date specified by the authority having jurisdiction. 1-3.2" When this standard is adopted by ajurisdiction, the authority having jurisdiction shall set a date or dates for cur- rent members to achieve compliance with the requirements of this standard and shall be permitted to establish a phase - in schedule for compliance with specific requirements of this standard in order to minimize personal and departmental disruption. 1582-3 14 Definitions. 14.1' Approved. Acceptable to the authority having juris- diction. 14.2• Authority Having jurisdiction. The org-anization, otTice, or individual responsible for appro%ing equipment, materials. an insullation. or a procedure. 14.3' Candidate. A person who has made application to commence performance as a member. 14.4 CategoryA Medical Condition. A medical condition that would preclude a person from performing as a member in a training or emergency operational environment by presenting a significant risk to the safety and health of the person or others. 14.5 Category B Medical Condition. A medical condition that. based on its severity or degree, could preclude a person from performing as a member in a u-tining or emergency operational environment by presenting a significant risk to the iafery and health of the person or others. 1. 4.6 Drug. Any substance, chemical, over-the-counter medi- cation. or prescribed medication that could affect the perfor- mance of the member. 14.7 Essential job Function. Task or assigned duty that is critical to successful performance of thejob. 14.8 Evaluation. See Medical Evaluation. 14.9 Exposure Incident. A specific eve, mouth, or other mucous membrane, non -intact skin, or parenterai contact with blood, bodv fluids, or other potentially infectious materi- als, or inhalation of airborne pathogens, ingestion of food - borne pathogens or toxins. 14.10 Fire Department Physician. The licensed doctor of medicine or osteopathy who has been designated by the fire department to provide professional expertise in the areas of occupational safety and health as they relate to emergency services. 14.11 Functional Capacity Evaluation. An assessment of the correlation between that individual's capabilities and the essential job functions. 14.12 Health and Fitness Coordinator. The person who, under the supervision of the fire department physician, has been desig- nated by the department to coordinate and be responsible for the health and fitness programs of the department I4.13 Health and Safety Officer. The member of the fire department assigned and authorized by the fire chief as the manager of the safety and health program and who performs the duties and responsibilities specified in this standard. This individual can be the incident safety officer or that can also be a separate function. 14.14 Infection Control Officer. The person or persons within the fire department who'are responsible for managing the department infection control program and for coordinat- ing efforts surrounding the investigation of an exposure. 14.15 Infection Control Program. The fire department's for- mal program relating to the control of infectious and commu- nicable disease hazards where employees, patients, or the general public could be exposed to blood, body fluids, or other potentially infectious materials in the fire department work environment. This program includes, but is not limited to, implementation of written policies and standard operating procedures regarding exposure follow-up measures, immuni- zations, members' health screening programs, and educa- tional programs. 2000 Edition 1582-i "FDi('-AL REQI.'IKE}TENTS FOR FIRE FIGHTEKS.\ND tNFOR}L\TION FOR FIRE DEP.\RrMENT PH1SICI.\NJ 14.16 Niedical Evaluation. The analysis of information for the purpose of making a determination of medical certifica- tion. Nledical evaluation can include a medical examination. 14.17 Medical Examination. An examination performed or directed by the fire department physician. 14.18 Nledical Services, Emergency. The provision of treat. ment—such as first aid, cardiopulmonary resuscitation, basic life support, advanced life support. and other pre -hospital pro- cedures including ambulance transportation —to patients. 14.19 Nledicaiiv Certified A determination by the fire depart- ment physician that the candidate or current member meets the medical requirements of this standard. 14.20' Member. A person involved in performing the duties and responsibilities of a fire department, under the auspices of the organization. A fire department member can be a full- time or part -rime employee or a paid or unpaid volunteer, can occupy any position or rank within the fire department- and can engage in emergency operations. 14.20.1 Member, Current. A person who is already a mem. ber and whose duties require the performance of essential fire -fighting functions. 14.21 Shall. Indicates a mandatory requirement. 14.2211 Should. Indicates a recommendation or that which is advised but not required. 14.23 Standard. A document, the main text of which con. tains only mandatory provisions using the word "shall" to indi- cate requirements and which is in a form generally suitable for mandatory reference by another standard or code or for adop- tion into law. Nonmandatory provisions shall be located in an appendix, footnote, or fine -print note and are not to be con- sidered a part of the requirements of a standard. 14-24 Tactical Level Management Component (TI MC). A management unit identified in the incident management sys tem commonly known as "division," "group," or "sector.- Chapter 2 Medical Process 2.1 Medical Evaluation Process. 2.1.1" The fire department shall establish and implement a medical evaluation process for candidates and current members. 2.1.2 The medical evaluation process shall include preplace- ment medical evaluations, periodic medical evaluations, and return-toduty medical evaluations. 2.1.3 The fire department shall ensure that the medical eval- uation process and all medical evaluations meet all of the requirements of Section 2.1. 2.1.4 Each candidate or current member shall cooperate, par- ticipate. and comply with the medical evaluation process and shall provide complete and accurate information to the fire department physician. 2-1.5• Each candidate or current member shall report, on a timely basis, to the fire department physician any exposure or medical condition that could interfere with the ability of the individual to perform as a member. 2.1-6 The medical evaluation shall be at no cost to the candi- date, current member. or other member. 2000 Edhon 2.2 Fire Department Roles. 2.2-1 The fire department shall have an officially designated physician who shall be responsible for guiding, directing, and advising the members with regard to their heath, fitness, and suitabilin for duty as required by NFPA 1500, Standard on Fir. D.partment Orrupational Safety and Health Progrum 2.2 2" The fire department physician shall be a licensed doc• tor of medicine or osteopathy. 2.2.3' For the purpose of conducting medical e-aluations, the fire department physician shall understand the physiolog. ical and psychological demands placed on members and shall understand the environmental conditions under which mem- bers must perform. The fire department shall provide the fire department physician with a currentjob description for all fire department positions and ranks. 2.2.4 The fire department shall require that the fire depart• ment health and safety officer and the health and fimess coor• dinator maintain a liaison with the fire department physician to ensure that the health maintenance process for the fire department is maintained. 2.2.5 Fire Department Physician Roles. 2.2.5.1 The fire department physician shall evaluate the per. son to ascertain the presence of any medical conditions listed in this standard. 2.2.5.2 When medical evaluations are conducted bva physician other than the fire department physician, the evaluation shall be reviewed and approved by the fire department physician. 2-3• Preplacement Medical Evaluation. 2.3.1 The candidate shall be terrified by the fire department physician as meeting the medical requirements of Chapter 3 of this standard prior to entering into a training program to become a member or performing in an emergency opera- tional environment as a member. 2.3.2 The candidate shall be evaluated according to the med- ical requirements of Chapter 3 of this standard to assess the effect of medical conditions on the candidate's ability to per- form as a member. 2.3.3 A candidate shall not be certified as meeting the medi- cal requirements of this standard if the fire department physi- cian determines that the candidate has any Category A medical condition as specified in Chapter 3 of this standard. 2-3.4' A candidate shall not be certified as meeting the med- ical requirements of this standard if the fire department phy- sician determines that the candidate has a Category B medical condition as specified in Chapter 3 of this standard that is of sufficient severity to prevent the candidate from performing, with or without reasonable accommodation. the essential functions of a member without posing a significant risk to the safety and health of the candidate or others. 2.3.4.1 The determination of whether a reasonable accom- modation shall be made by the authority having jurisdiction in conjunction with the Fire department physician. 2-3.5 If the candidate presents with an acute medical problem or newly acquired chronic medical condition that interferes with the candidate-s ability to perform the functions of mem- ber, medical certification shall be postponed until that person �IEDI(:.iL PROCE55 has recovered from this condition and presents to the tire department for review. 24• Periodic Medical Evaluation. 24.1 The current member shall be certified annually, or at the request of either the tire department or the member, by the fire department physician as meeting the medical require- ments of Chapter 3 of this standard in order to determine that member's medical ability to continue participating in a train- ing or emergency operational environment as a member..-Uv applicable OSH-4 standards, such as 21) (YR 1910.121). -Haz- ardous W:ute Operations and Emergency Response." 29 CFI? 11)10.134. "Respiratory Protection," `_9 (:'R 1910.95.-Occupa- tional Noise Exposure,' and 29 (1-R 11)10.1034),'Bloodb4)rne Pathogens,' shall be followed. 24.1.1 The components of the annual medical evaluauon as specified in 24.1.2 shall be permitted to be performed by qualified personnel as authorized by the tire department physician. When other qualified personnel are used, the tire department physician shall review the data gathered during the evaluation. 24.1.2 The annual medical evaluation shall consist of the fol- lowing- (1) An interval medical history (2) An interval occupational history, including significant exposures (3) Height and weight (4) Blood pressure (5) Heart rate and rhythm 2.4.1.3" In addition to the annual medical evaluation, the fire department shall include a medical examination according to the following schedule: (1) Ages 29 and under — at least every 3 years (2) Ages 30 to 39 — at least every 2 years (3) Ages 40 and above — every year 2.4.1.4' The medical examination shall include examination of the following components: (1) Vital signs — namely, pulse, respiration, blood pressure, and, if indicated, temperature (2) Dermatological system (3) Ears, eyes, nose, mouth, throat ('4) Cardiovascular system - (3) Respiratory system (6) Gastrointestinal system (7) Genitourinary system (3) Endocrine and metabolic systems (9) Musculeskeletal system (10) Neurological system (11) Audiometry (12) Visual acuity and peripheral vision testing (13) Pulmonary function testing (1.1) Laboratory testing, if indicated (15) Diagnostic imaging, if indicated (16) Electrocardiography, if indicated 24.2 Acurrent member shall not be certified as meeting the medical requirements of this standard if the fire department physician determines that the member has any Category A medical condition specified in Chapter 3 of this standard. 24.30 A current member shall not be certified as meeting the medical requirements of this standard if the fire department l53'2_7 physician determines that the member h.ts a Category B con- dition specified in Chapter 3 of this standard that is of suffi- cient seventy to prevent the member from pertoirning, with or without reasonable accommodation, the essential functions of a member without posing a si;nificant risk to the safety and health of the member or others. 24.3.1 The determination of reasonable accommodation shall be made by the authuriry hayingjurisdiction in conjunc. tion with the fire department physician. 24.4 if the current member presents with an acute illness or recently acquired chronic medical condition. the evalua- tion shall be deferred until the member has recovered from the condition and presents to the tire department to return to duty. 2-5 Return-to-Dury Medical Evaluation. 2-5.1' A current member who has been absent from duty for a medical condition of a nature or duration that could affect performance as a member shall be evaluated by the fire department physician before returning to duty. 2-5.2 The fire department physician shall not medically cer- tify the current member for return to duty if any Category A medical condition specified in Chapter 3 of this standard is present. 2-5.3' The fire department physician shall not medically cer- tify the current member for return to duty if any Category B medical condition specified in Chapter 3 of this standard is present that is determined to be severe enough to affect the member's performance as a member. The fire department physician, in conjunction with the authority having jurisdic- uon, shall take into account the member's current duty assign - merit and alternative duty assignments or other programs that would allow a member to gradually return to full duty. 2-5.4• The department shall provide guidance, opportunity, and encouragement to the member so as to expedite his safe return to full duty. 2-6 Medical Evaluadon Records, Results, Reporting, and Confidentiality. 2-6.1 All medical information collected as part of a medical evaluation shall be considered confidential medical informa- tion and shall be released by the fire department physician only with the specific written consent of the candidate or cur- rent member. 2-6.2 The fire department physician shall report the results of the medical evaluation to the candidate or current member, including any medical condition (s) disclosed during the med- ical evaluation, and the recomtnendation as to whether the candidate or current member is medically certified to perform as a member. 2-6.3 The fire department physician shall inform the fire department fire chief or designee only as to whether or not the candidate or current member is medically certified to per- form as a member. The specific written consent of the candi- date or current member shall be required in order to release confidential medical information regarding this condition to the fire department_ 2.6.4 All medical record keeping shall comply with the requirements of 29 CFR 1910.20, `Medical Recordkeeping." 2000 Edition 1582-3 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORNUTION FOR FIRE DEPARTMENT PM51CI.A.N5 Chapter 3 Category A and Category B Medical Conditions 3-1 Medical Conditions Affecting Ability to Perform. Cate- gory A and Category B medical conditions shall help the examiner understand the type of condition that could result in rejection or acceptance. The medical conditions listed are organized by organ system. In the corresponding Appendix A explanatory material, a diagnostic example is often included with the list. In addition, the rationale for the rejection is pre- sented in terms of the effect of the medical condition on the capability of the person to perform as a member. 3-2 Head and Neck- 3-2.1 Head. 3-2.1.1 There shall be no Category A medical conditions 3-2.1.2* Category B medical conditions shall include the fol- lowing: (1) Deformities of the skull such as depressions or exostoses (2) Deformities of the skull associated with evidence of dis- ease of the brain, spinal cord, or peripheral nerves (3) Loss or congenital absence of the bony substance of the skull (4) Any other head condition that results in a person not being able to perform as a member 3-2.2 Neck. 3-2.2.1 There shall be no Category A medical conditions 3-2.2.2* Category B medical conditions shall include the fol- lowing: (1) Thoracic outlet syndrome (2) Congenital cysts, chronic draining fistulas, or similar lesions (3) Contraction of neck muscles (4) Any other neck condition that results in a person not being able to perform as a member 3-3 Eyes and Vision. 3-3.1* Category A medical conditions shall include the fol- lowing: (a) Far visual acuity. Far visual acuity shall beat least 20/30 binocular, corrected with contact lenses or spectacles. Far visual acuity uncorrected shall beat least 20/100 binocular for wearers of hard contacts or spectacles. (b) Peripheral vision. Visual field performance without cor- rection shall be 140 degrees in the horizontal meridian in each eye. 3.3.2* Category B medical conditions shall include the fol- lowing: (1) Diseases of the eye such as retinal detachment, progres- sive retinopathy, or optic neuritis (2) Ophthalmological procedures such as radial keratotomy or repair of retinal detachment (3) Anyother cye condition that results in a person not being able to perform as a member 2000 Edition 3-4 Ean and Hewing. 3-4.1 There shall be no Category A medical conditions. 3-4.2* Category B medical conditions shall include the fol- lowing: (a) Hearing deficit in the pure tone thresholds in the unaided worst ear that is (1) Greater than 25 dB in three of the four frequencies a. 500 Hz b. 1000 Hz c. 2000 Hz d. 3000 Hz OR (2) Greater than 30 dB in any one of the three frequencies a. 500 Hz r b. 1000 Hz ! c. 2000 Hz AND (3) In addition averages greater than 30 dB for the four fre- quencies a. 500 Hz b. 1000 Hz c. 2000 Hz d. 3000 Hz (b) Unequal hearing loss (c) Atresia, severe stenosis, or tumor of the auditory canal (d) Severe external otitis (e) Severe agenesis or traumatic deformity of the auricle (f) Severe mastoiditis or surgical deformity of the mastoid (g) Meniere's syndrome or labyrinthitis (h) Odds media (i) Any other ear condition that results in a person not being able to perform as a member and results in a person being unable to pass a job -specific functional hearing task test or a hearing in noise test. 3.5 Dental. 3-5.1 There shall be no CategoryA medical conditions. 3-5.2* Category B medical conditions shall include the fol- lowing: (1) Diseases of the jaws or associated tissues (2) Orthodontic appliances (3) Oral tissues, extensive loss (4) Relationship between the mandible and maxilla that pre- cludes satisfactory postorthodontic replacement or abil- ity to use protective equipment (5) Any other dental condition that results in a person not being able to perform as a member 3-6 Nose, Oroplawynz, Trachea, Esophagus, and Larynx. 3-6.1* Category A medical conditions shall include the fol- lowing: (1) Tracheostomy (2) Aphonia 3-6.2* Category B medical conditions shall include the fol- lowing: (1) Congenital or acquired deformity (2) Allergic respiratory disorder CATEGORY A AND CATEGORY 3 MEDIC.AL CONDITIONS (3) Sinusitis, recurrent (4) Dysphonia (5) Anosmia (6) Any other nose, oropharynx, trachea, esophag-tu, or lar- ynx condition that results in a person not being able to perform as a member or to communicate effectively 3-7 Lungs and Chest Wall. 3-7.10 Category A medical conditions shall include the fol- lowing: (1) Active hemoptysis () Empyema (3) Pulmonary hypertension (4) Active tuberculosis 3-7.2" Category B medical conditions shall include the fol- lowing: (1) Pulmonary resectional surgery, chest wall surgery, pneu- mothorax (2) Bronchial asthma or reactive airways disease (3) F'ibrothorax:, chest wall deforrnity, diaphragm abnormalities (4) Chronic obstructive airways disease (5) Hypoxemic disorders (6) Interstitial lung diseases (7) Pulmonary vascular diseases, pulmonary embolism (8) Bronchiectasis (9) Infectious diseases of the lung or pleural space (10) Any other pulmonary condition that results in a person not being able to perform as a member 3.8 Heart and Vascular System. 3-8.1 Heart. 3-8.1.1' Category A medical conditions shall include the foi- iowing- (1) Angina pectoris, current (2) Heart failure, current (3) Acute pericarditis, endocarditis, or myocarditis (4) Syncope, recurrent (5) Automatic implantable cardiac defibrillator 3=5.1.2• Category B medical conditions shall include the fol- lowing: (1) Significant valvular lesions of the heart, including pros- thetic valves (2) Coronary artery disease, including history of myocardial infarction, coronary artery bypass surgery, or coronary angioplasty, and similar procedures (3) Atrial tachycardia, flutter, or fibrillation (4) Left bundle branch block, second- and third-degree atri- oventricular block (5) Ventricular tachycardia (6) Hypertrophy of the heart (7) Recurrent paroxysmal tachycardia (8) History of a congenital abnormality (9) Chronic pericarditis, endocarditis, or myocarditis (10) Cardiac pacemaker (11) Coronary artery vasospasm (12) Any other cardiac condition that results in a person not being able to perform as a member 1582-9 3-8.2 Vascular System. 3-8.2.1 There shall be no Category A medical conditions, 3-8.2.2' Category B medical conditions shall include the fol- lowing- (1) Hypertension (2) Peripheral vascular disease such as Raynaud's phenome- non (3) Recurrent thrombophlebitis (4) Chronic Ivmphedema due to lymphadenopathy or severe venous valvular incompetency (5) Congenital or acquired lesions of the aorta or major ves- sels (6) Marked circulatory instability as indicated by orthostatic hypotension, persistent tachycardia, and severe periph- eral vasomotor disturbances (7) Aneurysm of the heart or major vessel (8) Any other vascular condition that results in a person not being able to perform as a member 3-9 Abdominal Organs and Gastrointestinal System. 3.9.1 There shall be no Category A conditions. 3-9.2' Category B medical conditions shall include the fol- lowing- (1) Cholecystitis (2) Gastritis (3) GI bleeding (4) Acute hepatitis (5) Hernia (6) Inflammatory bowel disease (7) Intestinal obstruction (8) Pancreatitis (9) Resection, bowel (I0) Ulcer, gastrointestinal (11) Cirrhosis, hepatic or biliary (12) Chronic active hepatitis (13) Any other gastrointestinal condition that results in a per- son not being able to perform the duties of member 3-10 Genitourinary System. 3.10.1 Reproductive. 3-10.1.1 There shall be no Category A medical conditions. 3-10.1.2` Category B medical conditions shall include the fol- lowing- (1) Pregnancy, for its duration (2) Dysmenorrhea (3) Endometriosis, ovarian cysts, or other gynecologic con- ditions (4) Testicular or epididymal mils (5) Any other genital condition that results in a person not being able to perform as a member 3-10.2 Urinary System. 3-10.2.1 There shall be no Category A medical conditions 3-10.2.2• Category B medical conditions shall include the fol- lowing: (1) Diseases of the kidney (2) Diseases of the ureter, bladder, or prostate (3) Any other urinary condition that results in a person not being able to perform as a member tow Editn 1582-10 MEDICAL, REQUIREMENTS FOR FiRE FiCHTERS AND INFORSLiTION FOR FIRE DEPARTMENT PHISICLL\9 3-1 l Spine, Scapulae, Ribs, and Sacroiliac Joints. 3-1 l .1 There shall be no Category A medical conditions 3-11.2• Category B medical conditions shall include the fol- lowing: (1) Arthritis (2) Structural abnormality, fracture, or dislocation (3) Nucleus pulposus, herniation of, or history of laminec- tomy, discectomv or fusion (4) Ankylosingspondylitis (i) Anv other spinal condition that results in a person not being able to perform as a member 3-12 Extremities. 3-12.1 There shall be no Category A medical conditions. 3-12.2* Category B medical conditions shall include the fol- lowing- ( 1) Limitation of motion of a joint (2) Amputation or deformity of ajoint or limb (3) Dislocation of a joint (4) Joint reconsauction, ligamentous instability, or joint replacement (5) Chronic osteoarthritis or traumatic arthritis (6) Inflammatory arthritis (7) Any other extremity condition that results in a person not being able to perform as a member 3-13 Neurological Disorders. 3-13.1* Category A medical conditions shall include the fol- lowing: (1) Ataxias of heredo-degenerative type (2) Cerebral arteriosclerosis as evidenced by documented episodes of neurological impairment (3) Multiple sclerosis with activity or evidence of progression within previous three years (4) Progressive muscular dystrophy or atrophy (5) All epileptic conditions to include simple partial, complex partial, generalized, and psychomotor seizure disorders other than those with complete control during previous five years, normal neurological examination, and defini-tive statement from qualified neurological specialist. 3-13.2 if an epileptic member experiences a five-year seizure - free interval resulting from a change in the medical regimen, that individual shall not be cleared for return to fire -fighting duty until he or she has completed five years without a seizure on the new regimen. 3-13.3* Category B medical conditions shall include the fol- lowing: (1) Congenital malformations (2) Migraine (3) Clinical disorders with paresis, paralysis, dyscoordina- tion, deformity, abnormal motor activity, abnormality of sensation, or complaint of pain (4) Subarachnoid or intracerebral hemorrhage (5) Abnormalities from recent head injury such as severe cerebral contusion or concussion (6) Any other neurological condition that results in a person not being able to perform as a member 20M Edition 3-14 Sldn, 3-14.1 There shall be no Category A medical conditions. 3-14.2* Category B medical conditions shall include the fol- lowing: (1) Acne or inflammatory skin disease (2) Eczema (3) Any other dermatologic condition that results in the per- son not being able to perform as a member 3-15 Blood and Blood -Forming Organs. 3-15.1* Category A medical conditions shall include the fol- lowing: (1) Hemorrhagic states requiring replacement therapy (`_') Sickle cell disease (homozygous) 3.15-2* Category B medical conditions shall include the fol- lowing: (1) Anemia (2) Leukopenia (3) Polycythemiavera (4) Splenomegaly (5) History of thromboembolic disease (6) Anv other hematological condition that results in a per- son not being able to perform as a member 3-16 Endocrine and Metabolic Disorders. k3.16.1* Diabetes mellitus, which is treated with insulin or an oral hypoglycemic agent and where an individual has a history of one or more episodes of incapacitating hypoglycemia, shall be a Category A medical condition. 3-16.2* Category B medical conditions shall include the fol- lowing: (1) Diseases of the adrenal gland, pituitary gland, parathy- roid gland, or thyroid gland of clinical significance (2) Nutritional deficiency disease or metabolic disorder (3) Diabetes mellitus requiring treatment with insulin or oral hypoglycemic agent without a history of incapacitating hypoglycemia (4) Any other endocrine or metabolic condition that results in a person not being able to perform as a member 3-17 Systemic Diseases and Miscellaneous Conditions. 3.17.1 There shall be no CategoryA medical conditions. 3.17.2* Category B medical conditions shall include the fol- lowing- (1) Connective tissue disease, such as dermatomyositis, lupus erythematosus, scleroderma, and rheumatoid arthritis (2) Residuals from past thermal irijury (3) Documented evidence of a predisposition to heat stress with recurrent episodes or resulting residual injury (4) Any other systemic condition that results in a person not being able to perform as a member 3-18 Tumors and Malignant Diseases. 3-18.1 There shall be no Category A medical conditions. 3.18.20 Category B medical conditions shall include the fol- lowing: (1) Malignant disease that is newly diagnosed, untreated, or currently being treated. INCIDENT SCENE REI1A 3ILIT.IT[ON AND \,1EDlC_\L TRE.\T%(ENT a. Candidates shall be subject to the provisions of -3.5 of this standard. b. Current memhers shall be subject to the provisions of 24.4 of this standard. (2) Treated malignant disease that is evaluated on the basis of an individuals current physical condition and on [he likelihood of the disease to recur or progress. i ) Anv other tumor or similar condition that results in a per- son not being able to perform as a member. 3-19 Psychiatric Conditions. 3-19.1 There shall be no Category A medical conditions. 3-19.2* Category B medical conditions shall include the fol- lowing: (1) A history of psychiatric cundiuon or substance abuse problem (2) Any other psychiatric condition that results in a person not being, able to perform as a member 3-19.3 Candidates and current members shall be evaluated based on the individual's current condition. 3-20 Chemicals, Drugs, and dedications. 3-20.1 There shall be no Category A medical conditions. 3-20.2* Category B medical conditions shall include the use of the following- (1) Anticoagi.ilant agents (2) Cardiovascular agents (3) Narcotics (4) Sedative-hypnotics (5) Stimulants (6) Psychoactive agents (7) Steroids (8) Any other chemical, drug, or medication that results in a person not being able to perform as a member Chapter 4 Infectious Disease Program 4-1 Infection Control Program. 4-1.1 The fire department shall maintain infection control programs as delineated in NFPA 1581, Standard on Fire Depart- ment Infection ContraI Program. 4.1.2 The fire department physician shall maintain a liaison with the infection control officer as specified in NFPA 1581. 4-2 Exposure Incidents. 4-2.1* All blood and/or body fluid exposures shall be reported immediately. and medical assessment shall be pro- vided within 2 hours of exposure. Nfedical assessment shall conform to current CDC guidelines. 4-2.2* All other exposure incidents shall be reported and assessment provided within 24 hours of exposure. 4-3 Tuberculosis. 4-3.1" The fire department shall provide a tuberculosis mon- itoring program that will test members at least annually and as indicated by CDC guidelines. Tuberculosis (TB) testing inter- vals shall conform to current CDC guidelines. 1382-II 1-3.2* All members shall be evaluated according to current CDC guidelines following any tuberculosis exposure. These results shall be communicated to and revie-ed by the fire department pluaician. 4-4* Immunizations. All members shall he immunized ai;ninst infecuous diseases as required by the authority having jurisdiction and by 29 UR 1910.10:5U-Bl,r)dborne Patho- gens.- The fire department physician shall ensure that all members are offered currently recommended immunizations. Chapter 5 Incident Scene Rehabilitation and ,Medical Treatment 5-1 Incident Scene Rehabilitation. 5-1.1* The fire department shall develop standard operating procedures that outline a systematic approach for the rehabil- itation of members operating at incidents. Provisiuns addressed in these procedures shall include medical evalua- tion and treatment, food and fluid replenishment, crew rota- tion, and relief from extreme climatic conditions. 5.1.2* The incident commander shall consider the circum- stances of each incident and initiate rest and rehabilitation of members in accordance with the fire department's standard operating procedures and with NFPA 1561, Standard on Emer- grncy Se7 ces Incident Management System 3-2 Incident Scene Safety and Health. 5.2.1 The incident safety officer shall ensure that the incident commander establishes an incident scene rehabilitation tacti- cal level management component during emergency opera- tions as required by NFPA 159'1, Standard for Fite Department Safety Officer: 5.2.2* Transport capable emergency medical services (EdS) 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 preferable where it is available. 5.3 Evaluation and Triage of Member Injuries. 5-3.1 In the event of an injury to a member during emergency operations, EMS personnel shall assess and treat the injury based on local EMS protocol and fire department standard operating procedures. 5.3.2* Protocols and procedures guiding EMS providers car- ing for ill or injured members during emergency operations shall be developed by the EMS medical director in collabora- tion with the fire department physician and chief. 5-4 Incident Scene Rehabilitation Tactical Level Management Component. 5-4.1 The rehabilitation tactical level management compo- nent shall be designated per department standard operat- ing procedures, such as large-scale incidents, long -duration incidents, or those associated with significant temperature extremes. 5-4.2 The rehabilitation tactical level management compo- nent shall be established in a safe environment away from the hazardous area of the incident. 2000 Edition 158 `-l'_' RLQL IRV IENIS FOR FIRM: FIG rERi AND INFORNIA MAN FOR FIRE DEPART,%ILNT PiMNICI.vN 54.3• The resources needed at the rehabilitation tacucal level management component shall include an environment to limit temperature stress. medical equipment. and adequate medical staff. 5-4.4' Members shall be assigned to rehabilitation as pre- scribed by departmental standard operating procedures. Unusual circumstances. such as long -duration incidents, situa- tions requiting heavy exertion, or severe weather extremes shall require an alteration in procedures. 5-4.3' Members arriving at rehabilitation shall be bnetly questioned by medical stab about any symptoms of dehvdta- tion, heat stress. cold ,tress, physical exhaustion. and; or car- diopulmonary abnormalities. Anv member having signiticant svmptoms shall be moved to an area where assessment by advance life support personnel can be performed. 5-4.6 Members assigned to rehabilitation shall be encouraged to add; remove clothing to regain normal body temperature, drink fluids (seater, electrolyte replacement drinks), and rest. 54.7 No member shall he reassigned to return to dua until medical evaluation and hydration has occurred for at least 10 minutes in rehabilitation and after being cleared by medical staff. 5-4.8 All members entering and leaving rehabilitation shall be properly assigned by the incident management system and be tracked through the personnel accountability system. Chapter 6 Referenced Publications 6-1 The following documents or portions thereof are refer- enced within this standard as mandatory requirements and shall be considered part of the requirements of this standard. The edition indicated for each referenced mandatory docu- ment is the current edition as of the date of the NFPA issuance of this standard. Some of these mandatory documents might also be referenced in this standard for specific informational purposes and, therefore, are also listed in Appendix F. 6-1.1 NFPA Publications. National Fire Protection Associa- tion, I Batterymarch Park, P.O. Box 9 10 1, Quincy. NLk 02269- 9101. NFPA 1500, .Standard on Fire Department Occupational Safety and Health Program, 1997 edition. NFPA 1521, Standard for Fire Department Safety Officer, 1997 edition. NFPA 1561, Standard on Emergency Services Incident Manage- ment System, 2000 edition. NFPA 1581. Standardim Fire. Department Infection Control Pro- gram, 2000 edition. 6-1.2 U. S. Government Publications. U.S. Government Print- ing Office, Washington, DC M 401. Title 29, Cade of Federal Regulations, Part 1910,124). 'Hazard- ous Waste Operations and Emergency Response," 1986. Title 29, Code of federal Regulations, Part 1910.134, "Respira- tory Protection," 1998, Title 29, Cale of Fedmd R.gulahom, Part 1910.95, `Occupa- tional Noise Exposure." 1980. Title 29. Cady of Federal Regr/ulaons, Part 1910.20, "Medical Recordkeeping," 1980, Title 29, rode of Federal Reg alatums, Part 1910 1030, "Blood - borne Pathogens," PY)5, 2000 Edacn Appendix A Explanatory Material ,4pp,milix ,{ u not n pnri of the requirements of thcs .NFPA 'G,eu. merit but Ls included for infmnahonal purpises only. This app•rtdix ,-oniain.s rxplarzalnry material, numbered to rorrespond wall the appli. able text paragraphs. A-1-2.2 There is a direct relationship between the medical requirements and the job description of members. The job description should include all essentialjob functions of mem- bers, both emergency and nonemergency. Members perform a variety of emergency operations including tire fighting, emergency medical care, hazardous materials mi igrttion, and special operations. i lonemergency duties can include, and are not limited to, training, station and vehicle maintenance, and physical fitness. Each fire department needs to identify and develop a written job description for members. Appendix C, Essential Fire -Fighting Functions. provides an example of essential job Functions for members. A-1-3.2 The specific determination of the authority having jurisdiction depends on the mechanism under which this stan- dard is adopted and enforced. Where this standard is adopted voluntarily by a particular fire department for its own use, the authority having jurisdiction should be the fire chief or the political entity that is responsible for the operation of the fire department. Where this standard is legally adopted and enforced by a body having regulatory authority over a fire department, such as federal. state, or local government or political subdivision, this body is responsible for making those determinations as the authority having jurisdiction. The com- pliance program should take into account the services the fire department is required to provide, the financial resources available to the fire department, the availability of personnel, the availability of trainers, and such other factors as will affect the fire department's ability to achieve compliance. A-14.1 Approved. The Natonal Fire Protecdon Associadon does not approve, inspect, or certify any installations, proce- dures, equipment, or materials; nor does it approve or evalu- ate testing laboratories. In determining the acceptability of installations, procedures, equipment, or materials, the author- ity having jurisdiction may base acceptance on compliance with NFPA or other appropriate standards. In the absence of such standards, said authority may require evidence of proper installation, procedure, or use. The authority havingjurisdic- tion may also refer to the listings or labeling practices of an organization that is concerned with product evaluations and is thus in a position to determine compliance with appropriate standards for the current production of listed items. A-1 4.2 Authority Having jurisdiction- The phrase "authority having jurisdiction" is used in NFPA documents in a broad manner, since junsdictions and approval agencies vary, as do their responsibilities. Where public safety is primary, the authority having jurisdiction may be a federal, state, local. or other regional department or individual such as a fire chief: fire marshal: chief of a fire prevention bureau, labor depart- ment, or health department, building official; electrical inspector; or others having statutory authority. For insurance purposes, an insurance inspection department, rating bureau, or other insurance company representative may be the author- ity having jurisdiction. In many circumstances, the property owner or his or her designated agent assumes the role of the authority having jurisdiction; at govemment installations, the at'PEVDC:.\ 158'2-1:1 commanding officer or departmental otlicial may be the A-2-5.3 See .appendix D, Section D-1. Legal Considerations in audvonty having jurisdiction• applying the Standard. A-14.3 Candidate. In an employment contest, the Ameri- cans with Disabilities act (discussed in furtherdetail inAppen- dix D) requires that any medical examination to be conducted rake place after an offer of employment is made and prior to the commencement of duties. Therefore, in the employment contest, the definition of the term cariohdaleshould be applied so as to be consistent with that requirement. Volunteer members have been deemed to be employees in some states or jurisdictions. Volunteer fire departments should seek legal counsel as to their legal responsibilities in these matters. A-14.20 Member. See appendix C, Essential Stmcatral Fire- FightingFunctions. A-2.1.1 See .appendix D. Guide for Fire Department Adminis. trators. A-2-1.5 Exposures and medical conditions that should be reported if they can interfere with the ability of the individual to perform as a member include, but are not limited to, the following: (1) Exposures to hazardous materials or toxic substances (2) Exposure to infectious or contagious diseases (3) Illness or injury (4) Use of prescription or nonprescription drugs (5) Pregnancy A-2-2.2 See Appendix D, Section D-2, Choosing a Fire Depart- ment Physician. A-2.2.3 See Appendix B. Information for Fire Department Physicians. Appendix C, Essential Sauctural Fire-Fighung Functions provides a generic description of job tasks per- formed by members. A fire department needs to provide the fire department physician with a job description of all posi- tions and ranks so that the fire department physician can understand the physical and mental demands placed upon all members regardless of position or rank. appendix D, Guide for Fire Department administrators, also provides guidance for ensuring that the fire department physician is provided with this information. A-2.3 See appendix B, Section B-3, Guidance for Medical Evaluations. A-2-3.4 See Appendix D, Section D- 1. Legal Considerations in Applying the Standard. A-2-4 See appendix B. Section B-3, Guidance for Medical Evaluations. A-2-41.1.3 At the discretion of the fire department physician, an examination can be performed sooner than would be expected from the schedule ,given in 2-4.1.3. Current medical conditions and coronary risk factors could mandate more fre- quent medical examinations. A-24.1.4 See Appendix B, Guide for Fire Department Phy- sicians. A-24.3 See Appendix D, Section D- 1. Legal Considerations in Applying the Standard. A-2-5.1 A department should set protocols regarding length of time absent from duty and/or medical conditions that require the department physician to evaluate a member. A-2-5.4 Physical therapy, strength training, work hardening, functional capacity evaluations, and alternate dury are all activ- ities that can be helpful. A-:3-2.1.2 Category B medical conditions of the head include the following (1) Deformities of the skull. such as depressions or exos- roses, of a degree that interferes with the use of protec- tive equipment. Deformities of the skull can result in the- member's inability to properly wear protective equipment. (2) Deformities of the skull associated with evidence of dis- ease of the brain, spinal cord, or peripheral nerves. These deformities can result in the potential for sudden inca. pacitation, the inability to properly wear protective equipment. and the inability to communicate effectively due to oropharyngeal dysfunction. (3) Loss ofor congenital absence of the bony substance of the skull (if associated with disease interfering with perfor- mance or ifappropriate protection cannot be provided for the area without interfering with protective equipment and vision). Loss of or congenital absence of the bony sub- stance of the skull can result in the inability to properly wear protective equipment and the inability to communi- cate effectively due to oropharyngeal dysfuncuon. (4) Any other head condition that results in a person not being able to perform as a member. .'►3-2.2.2 Category B medical conditions of the neck include the following: (1) Thoracic outlet syndrome (symptomatic). Thoracic out- let syndrome can result in frequent episodes of pain or inability to perform work. (2) Congenital cysts, chronic draining fistulas, or similar lesions (if lesions or underlying disease interferes with performance). Congenital cysts, chronic draining fistu- las, or similar lesions can result in the inability to properly wear protective equipment, and the inability to commu- nicate effectively due to oropharyngeal dysfunction. (3) Contraction of neck muscles (if it interferes with wearing of protective equipment or ability to perform duties). The contraction of neck muscles can result in the inabil- ity to properly wear protective equipment, and the inabil- ity to perform functions as a member due to limitation of flexibility. (4) Any other neck condition that results in a person not being able to perform as a member. A-3-3.1 Category A medical conditions of the eves and vision include the following: (1) Far visual acuity. Far visual acuity is at least 20,130 binocu- lar, corrected with contact lenses or spectacles. Far visual acuity uncorrected is at least 201100 binocular for wear- ers of hard contacts or spectacles. Successful long-term soft contact lens wearers (that is, six months without a problem) are not subject to the uncorrected standard. Inadequate far visual acuity can result in the failure to be able to read placards and street signs or to see and respond to imminently hazardous situations. (`_') Periphertt<vision. Visual field performance without correc- tion is 140 degrees in the horizontal meridian in each eye_ (Members cannot have just monocular vision.) 2000 Edition 15812-I 1 -1['01C u. REQUIREM E.NTS FOR I'IRL•' FIGI ITERS '.ND INFOKAL FTON FOP FIRC DCP.UtT%IE.NT P[ltiNWIANS Monocular vision can result in sudden incapacitation when debris is lodged in one eye. Inadequate or compro - raised peripheral vision can result in the following: a. Failure to perforrnjob duties and maintain visual con- tact with a partner b. Inability to maintain safety near moving, objects c. Poor balance on uneven surfaces d. [insuccessful performance in environments %.here Visual cues are critical to personal safety A-3-3.2 Category B medical conditions of the eves and vision include the follo%,in;,: ( l) Diseases of the eve such as retinal detachment, progres. sive retinopathy, or optic neuritis (severe or progressive). These diseases of the eye can result in the failure to read placards and street signs or to see and respond to immi- nently hazardous situations. (2) Ophthalmological procedures such as radial keratot- omv and repair of retinal detachment. With retinal detachment, sufficient time 0-2 weeks for radial kera- tonomy and Lasik-type surgeries, three months for reti- nal detachment) must have passed to allow stabilization of visual acuity and to ensure that there are no posrsur. gical complications. These ophthalmological proce- dures may result in the failure to be able to read placards and street signs or to see and respond to imtni- nently hazardous situations, (3) Any other eye condition that results in a person not being able to perform as a member. Persons with severe color vision loss will likely fail the acuity requirement. Formerly, color vision deficiency was listed as a Cate- gory B medical condition. However, it is felt that within most cases this condition will not affect the ability of a member to perform the essential functions of his or her job. The fire service physician should consider the color vision deficiency of the individual and consider the color vision requirements of the member's job and reach an individual determination. A-3-4.2 There are currently no hearing tests that will allow the fire deparunent physician to accurately predict whether the fire fighter will adequately be able to perform essential job duties. Job -specific hearing tests should be individualized for each department and its specificjob functions. The following list of hearing -specific tasks can assist to direct development of hearing protocols. (1) Understanding spoken commands, both over the radio and while wearing SCBA (2) Hearing alarm signals, including building evacuation, low air signal on the SCBA, and PASS alarms (3) Hearing and locating the source of calls for assistance from victims or other fire fighters All of the above tasks will need to be performed with rea- sonably simutlated incident scene background noise and SCBA noise. The inability to hear sounds of low intensity or to distin- guish voice from background noise can lead to failure to respond to imminently hazardous situations. (See also li--I.S. ) Category B medical conditions of hearing include the fol- lowing: (aj Unequal hearing can result in the inability to localize sounds, leading to failure in the ability to perform search and rescue and other localization tasks. :000 Edition (bi Severe external otitis, that is, reunrent loss of hearing can result in the inability to hear sounds of low intensity or to distinguish voice from background noise, leadingr to failure to respond to imminently hazardous situations. (c) Severe agenesis or traumatic deformity of the auricle can result in the inability to properly wear protective equip- ment and the inability to hear sounds of low intensity or to dis. tiny,*uish voice from background noise, leading to failure to respond to imminently hazardous situations. (d) Severe ntastoiditis or surgical defotmiry of the mastoid can result in the inability to properly %vear protective equip. ment and the inability to hear sounds of low intensity or to dis- tin6ptish voice from background noise, leading to failure to respond to imminently hazardous situations. (e) Meniere'.i syndrome or severe labyrinthitis may result in the potential for sudden incapacitation and the inability to perform job functions due to limitations of balance. (f) Otitis media (chronic) can result in frequent episodes of pain or the Inability to perform work and the inability to hear sounds of low intensity or to disun6ruish voice from back- ground noise, leading to failure to respond to imminently haz- ardous situations. (g) Any other ear condition that results in a person not being able to perform as a member can be classified as a Cat- el-ory B medical condition of hearing. A-3-5.2 Category B dental medical conditions include the fol- lowing: (1) Diseases of the jaws or associated tissues ( those that are incapacitating or preclude ability to use protective equipment). Diseases of the jaws or associated tissues can result in the inability to properly wear protective equipment. (2) Orthodontic appliances (those that preclude the ability to use protective equipment). The wearing of orthodon- tic appliances can result in the inability to properly wear protective equipment. (3) Oral tissues, extensive loss (that which precludes satisfac- tory postorthodontic replacement or ability to use pro- tective equipment). Extensive loss of oral tissues may result in the inability to properly wear protective equip- ment and the inability to communicate effectively due to oropharyngeal dysfunction- (4) Relationship between the mandible and maxilla that pre- cludes satisfactory postorthodontic replacement or abil- ity to use protective equipment. This condition can result in the inability to properly wear protective equipment and the inability to communicate effectively due to oropharyngeal dysfunction. (5) Any other dental condition t$at results in a person not being able to perform as a member. A-3.6.1 Category A medical conditions of the nose, orophar- ynx, trachea, esophagus, and larynx include the following: (I) Tracheostomy. A tracheostomy can result in the inability to properly wear protective equipment, the inability to perform job functions due to limitations of endurance, and the inability to communicate effectively due to oropharyngeal dysfunction. (2) Aphonia, regardless of cause. Aphonia can result in the inability to communicate effectively due to oropharyn- geal dysfunction. .aPPEVDIXA A-3-6.2 Category B medical conditions of the nose, orophar- vnx, trachea, esophagus, and larynx include the following: (1) Congenital or acquired deformity that interferes with the ability to use protective equipment. A congenital or acquired deformity can result in the inability to properly wear protective equipment. (2) AAerTc respiratory disorder (uncontrolled). ,filer; c res- piratory disorder can result in frequent episodes of pain, the inability to perform work, and the inability to perform functions as a member due to limitations of endurance. (3) Sinusitis. recurrent (severe, requiring repeated hospital- izauons or causing impairment). Recurrent sinusitis can result in frequent episodes of pain and the inability to perform work. (4) Dvsphonia (severe). Severe dvsphonia can result in the inability to communicate effectively due to oropharyn- geal dysfunction. (5) Anv other nose, oropharnx, trachea, esophagus, or lar- ynx condition that results in a person not being able to perform as a member or to communicate effectively. A-3.7.1 Cate ory.A medical conditions of the lungs and chest wall include active hemoptysis, empyema, pulmonary hyper- tension, and active tuberculosis. These conditions can result in the inability to perform functions as a member due to limi- tations of endurance. A-3-7-2 Category B medical conditions of the lungs and chest wall include the following: (1) Pulmonary resecdonal surgery, chest wall surgery, pneu- mothorax (that is, history of recurrent spontaneous pneumorhorax). These conditions can result in the inability to perform functions as a member due to limita- tions of strength or endurance and may result in the potential for sudden incapacitation. (2) Bronchial asthma or reactive airways disease (frequent medication use or symptoms caused by exposures to exer- tion, heat and cold, or products of combustion and other irritant inhalation). Bronchial asthma or reactive airways disease can result in frequent episodes of pain or the inability to perform work, the potential for sudden inca- pacitation, and the inability to perform functions as a member due to limitations of endurance. (3) Fibrothotax, chest wall deformity, diaphragm abnormali- ties. Fibrothorax, chest wall deformity, and diaphragm abnormalities can result in the inability to perform func- tions as a member due to limitations of endurance. (4) Chronic obstructive airways disease. Chronic obstructive airways disease can result in the inability to perform func- tions as a member due to limitations of endurance. (5) Hypoxemic disorders. Hvpoxemic disorders can result in the inability to perform functions as a member due to limitations of endurance. (5) Interstitial lung diseases. Interstitial lung diseases can result in the inability to perform functions as a member due to limitations of endurance. (7) Pulmonary vascular diseases, pulmonary embolism. Pul- monary vascular diseases and pulmonary embolism can result in frequent episodes of pain and the inability to perform functions as a member due to limitations of endurance. (8) Bronchiectasis with significant residual impairment of pulmonary function or requiring frequent therapy. Bron- chiectasis can result in the inability to perform functions as a member due to limitations of endurance. 1582-15 (9) Infectious diseases of the lung or pleural space. ( U}) Any other pulmonary condition that results in a person not being able to perform as a member. A-3.8.1-1 Category A medical conditions of the heart and vas- cular system include the following: ( 1) Angina pectoris. current. Angina pectoris can result in frequent episodes of pain or inability to perform work, progressive illness leading to functional impairment, and the potential for sudden incapacitation. (2) Heart failure, current. Heart failure can result in fre- quent episodes of pain or inability to perform work, pro. gressive illness leading to functional impairment, and the potential for sudden incapacitation. (3) Acute pericardids, endocardids, or mvocarditis. These conditions can result in frequent episodes of pain or the inability to perform work. (4) Syncope, recurrent. Recurrent svncope can result in the potential for sudden incapacitation. (5) Automatic implantable cardiac defibrillator. An auto- mauc implantable cardiac defibrillator can result in the potential for sudden incapacitation. 3 3-8.1.2 Category B medical conditions of the heart and vas- cular system include the following: (1) Significant valvular lesions of the heart, including pros- thetic valves. Specific recommendations include the fol- lowing: a. Nlitrdl sterwis. Mitral stenosis is acceptable if in sinus rhythm and stenosis is mild, that is, valve area > 1.5 cm2 or pulmonary artery systolic pressure < 35 mm Hg. b. AIitral insufficiency. Miu•al insufficiency is acceptable if in sinus rhythm with normal left ventricular size and function. c. Aortic stenosis. Aortic stenosis is acceptable if stenosis is mild, that is, mean aortic valvular pressure gradi- ent < 20 mm Hg. d. Aortic regurgitation. Aortic regurgitation is acceptable if left ventricular size is normal or slightly increased and systolic function is normal. C. Prosthetic valves. Prosthetic valves are acceptable unless full anticoagulation is in effect. (2) Coronary artery disease, including history of myocardial infarction, coronary artery bypass surgery, coronary angioplasty, and similar procedures. Persons at mildly increased risk for sudden incapacitation are acceptable for fire fighting. Mildly increased risk is defined by the presence of each of the following: a. Formal left ventricular ejection fraction b. Normal exercise tolerance, > 10 metabolic equivalents ( NETS) c. Absence of exercise4nduced ischemia by exercise testing d. Absence of exercise -induced complex ventricular arrhythmias e. Absence of hernodynamically significant stenosis on all major coronary arteries (�t50 percent lumen diameter narrowing), or successful myocardial revascularization (3) Atrial tachycardia, flutter, or fibrillation (4) Left bundle branch, second- and third-degree arrioven- tricular block. These blocks will result in disqualification unless exercise can be performed with an adequate heart rate response. They can result in frequent episodes of pain, the inability to perform work, and have the poten- tial for sudden incapacitation. 2000 Edition 1382-16 N(EDIG\L RL•-QUIRENIEN'TS FOR FIRE FN14(TERi .\VD (NFORNL\rION rO K FIRE DLP \RTM NT P(t�` ICLO`S 15) Ventricular tachvcardia. Ventricular tachycardia can result in the potential for sudden incapacitation and the inability to perform job funcuons due to limitations of strength or endurance. (5) H\prrtrophv of the heart Hypertrophy of the heart can result in the potential for sudden incapacitation and the inability to perform job functions due to limitations of endurance. (7) Recurrent paroxysmal tachycardia. Recurrent paroryy- mal L-ichvcardia can result in the potential for sudden incapacitation and the inability to perform job functions due to limitations of strength or endurance. (8) History of a congenital abnormality that has been treated bysurgery but with residual complications or that has not been treated by surgery, leaving residuals or complica- uons. A congenital abnormality can result in frequent episodes of pain or inability to perform work and the potential for sudden incapacitation. (9) Chronic pericarditis, endocarditis, or myocarditis. These conditions can result in the inability to perform job func- tions due to limitations of endurance. (10) Cardiac pacemaker. If the person is pacemaker -depen- dent, then the risk for sudden failure due to trauma is not acceptable. Those with cardiac pacemakers can have the potential for sudden incapacitation- (11) Coronary artery vasospasm. Those with cardiac artery vasospasm can have the potential for sudden incapaci- tation. (12) .any other cardiac condition that results in a person not being able to perform as a member. A-3-8.2.2 Category B medical conditions of the vascular sys- tem include the following: (1) Hypertension that is uncontrolled, poorly controlled, or requires medication likely to interfere with the perfor- mance of dunes. Acceptable hypertension is a blood pres- sure less than 190/ 100 and no target organ damage. Hypertension is a progressive illness leading to functional impairment with the potential for sudden incapacitation. (2) Peripheral vascular disease, such as Raynaud's phenome- non, that interferes with performance of duties or makes the individual likely to have significant risk of severe injury. Peripheral vascular disease can result in frequent episodes of pain or the inability to perform work and the inability to perform functions as a member due to limita- tions of endurance. (3) Recurrent thrombophlebitis. Recurrent thrombophlebi- tis can result in frequent episodes of pain or the inability to perform work and the inability to perform functions as a member due to limitations of endurance. (41 Chronic lymphedema due to lymphopathy or severe venous valvular incompetency. Chronic lyrnphedema can result in the inability to perform functions as a member due to limitations of endurance. (5) Congenital or acquired lesions of the aorta or major ves- sels, for example, syphilitic aortitis, demonstrable athero- sclerosis that interferes with circulation, and congenital acquired dilatation of the aorta. Congenital or acquired lesions of the aorta or major vessels can result in the potential for sudden incapacitation and the inability to performjob functions due to limitations of endurance. (6) Marked circulatory instability as indicated by orthostatic hypotension, persistent tachycardia, and severe periph- eral vasomotor disturbances. Marked circulatory instabil- ity can result in the inability to perform job functions due 2000 Edition to limitations of endurance and the inability to perform job functions due to limitations of balance. () Aneurysm of the heart or major vessel, congenital or acquired. An aneurysm of the heart or major vessel can result in frequent episodes of pain, the inability to per- form work, and the potential for sudden incapacitation. S) Anv other vascular condition that results in a person not being able to perform as a member. -39.`' Category B medical conditions of the abdominal organs and gastrointestinal system include the following: 1) Cholecvstitis ( that which causes frequent pain due to stones or infection). Cholecysutis can result in frequent episodes of pain or the inability to perform work. (2) Gastritis (that which causes recurrent pain and impair- ment). Gastritis can result in frequent episodes of pain or the inability to perform work. (3) GI bleeding can cause fatigue, and or hemodynamic instability resulting in inability to perform work. (6) Acute hepatitis (until resolution of acute hepatitis as determined by clinical examination and appropriate lab- oratory testing). Acute hepatitis can result in frequent episodes of pain or the inability to perform work. (5) Hernia (unrepaired inguinal or abdominal hernia that could obstruct during duty). A hernia can result in the potential for sudden incapacitation. (6) Inflammatory bowel disease (that which causes disabling pain or diarrhea). Inflammatory bowel disease can result in frequent episodes of pain or the inability to perform work. It is a progressive illness leading to functional impairment. (^) Intestinal obstruction (that is, recent obstruction with impairment). An intestinal obstruction can result in fre- quent episodes of pain, the inability to perform work. and the potential for sudden incapacitation. (3) Pancreatitis (that is, chronic or recurrent with impair- ment). Pancreatitis can result in frequent episodes of pain or the inability to perform work. (9) Resection, bowel (if frequent diarrhea precludes perfor- mance of duty). A bowel resection can result in frequent episodes of pain or the inability to perform work. (10) Ulcer, gastrointestinal (where symptoms are uncon- trolled by drugs or surgery). A gastrointestinal ulcer can result in frequent episodes of pain or the inability to per- form work- (11) Cirrhosis, hepatic or biliary (that which is symptomatic or in danger of bleeding). Cirrhosis can result in frequent episodes of pain or the inability to perform work- (12) Chronic active hepatitis. Chronic, active hepatitis can result in frequent episodes of pain or the inability to per- form work. (13) Anv other gastrointestinal condition that results in a per- son not being able to perform as a member. A-3-10.1.2 Category B medical conditions of the reproductive organs include the following: (1) Pregnancy. Pregnancy can result in frequent episodes of pain or the inability to perform work, progressive inabil- ity to perform work due to limitations of endurance, flex- ibility, or strength. and the inability to properly wear protective equipment (Sere B-4.4. Repmductive.) (2) Dysmenorrhea that leads to recurrent incapacitation. Dysmenorrhea can result in frequent episodes of pain or the inability to perform work. .1PrENDIX .k (3) Endometriosis, ovarian cysts, or other ,pmecolo.gic condi- tions (severe, leading to recurrent incapacitation'). Endometriosis, ovarian cysts, and other gynecologic con- ditions can result in frequent episodes of pain or the inability to perform work. ( 4) Testicular or epididvmal mans (that which requires medi- cal evaluation). A testicular or epididymal mass can result in frequent episodes of pain or the inability to perform work. This is a progressive illness leading; to functional impairment. (5) Anv other genital condition that results in a person not being able to perform as a member. A-3-10.2.21' Category B medical conditions of die urinary sys- tem include the following: (1) Diseases of the kidney requiring dialysis. Diseases of the kidney can result in frequent episodes of pain or the inability to perform work. Kidney disease is a progressive illness leading to functional impairment. (_) Diseases of the ureter, bladder, or prostate that require frequent or prolonged treatment. These diseases can result in frequent episodes of pain or the inability to per- form work. (3) Any other urinary condition that results in a person not being able to perform as a member. A-3-11 2 Category B medical conditions of the spine, scapu- lae, ribs, and sacroiliac joints include the following: Arthritis that results in progressive impairment or limita- tion of movement- Arthritis is a progressive illness that leads to functional impairment. Arthritis can result in the inability to perform functions as a member due to limita- tions of endurance or flexibility. Structural abnormality, fracture, or dislocation that is a progressive or recurrent impairment. These conditions are progressive illnesses leading to functional impair- ment. These illnesses can result in the inability to per- form functions as a member due to limitations of strength or flexibility. Nucleus pulposus, herniation of, or history of laminec- comy, discectomy, or fusion. These conditions are pro- gressive illnesses leading to functional impairment and the inability to properly wear protective equipment. Ankylosing spondylitis. This condition can result in the inability to perform functions as a member due to limita- tions of endurance or flexibility. Any other spinal condition that results in a person not being able to perform as a member. A-3-12.2 Category B medical conditions of the extremities include the following: (1) Limitation of motion of ajoint of a degree to interfere with successful and safe performance of fire -fighting duties. The limitation of motion of ajoint can result in the inability to perform functions as a member due to limitation of flexibility. (2) Amputation or deformity of ajoint or limb of a degree to interfere with successful and safe performance of fire- fighting duties. The amputation or deformity of ajoint or limb can result in the inability to perform functions as a member due to limitations of strength and/or balance. (3) Dislocation of ajoint. Recurrent dislocation of ajoint or dislocation with residual limitation of motion of degree to interfere with successful and safe performance of fire- fighting duties; successful surgery for recurrent shoulder (4) (3) (6i 138';-t dislocation, it range of motion i., intact, would not exclude a person. Dislocation ot'.i joint can result in the inabilin to perform functions as a member due to limita- tions of strength or flexihilirv. Joint reconstruction, ligamentous instability, or joint replacement. In cases where recurrent or with residual limitation of motion of a degree to) interfere )nth success- ful and safe performance rat tire-ti,htin, dunes, surger✓ for a torn anterior cntaate li;-amcnt could disqualify if quadricep strength is not norm.il or it the knee is lax or develops pain or swelling when stressed. These condi- tions of cite joint can result in the inability to perform functions as a member due to limitations of scrength or fexibilin. Chronic osteoaidiritis or craum:uic arthritis tin cases where recurrent exacerbations leads to impairment). Chronic osceoarthrius or traumatic arthritis can result in trequent episodes of pain, the inabiliry to perform work, and the inability to perform tunctions as a member due to limitations of strength, endurance, or flexibility. Inflammatory arthritis (in cases where it is severely recur- rent or a progressive illness or with deformity or limita- tion of range of motion of a degree to interfere with successful and safe performance of fire -fighting duties). Inflammatory arthritis can result in frequent episodes of pain, the inability to perform work, and the inability to perform functions as a member due to limitations of strength, endurance, or flexibilicv. Any other extremity condition chat results in a person not being able to perform as a member. A-3-13.1 Category A medical conditions of a neurological nature include the following: (a) Ataxias of the heredo-degenerative rape. Ataxias of the heredo-degenerative type can result in the inability to perform functions as a member due to limitations of balance. (b) Cerebral arteriosclerosis as evidenced by documented episodes of neurological impairment. Cerebral arteriosclero- sis can result in the inability to perform functions as a member due to limitations of strength and/or balance. (c) Progressive multiple sclerosis or multiple sclerosis with evidence of progression within previous three years. INIuldple sclerosis can result in the inability to perform functions as a member due to limitations of strength or flexibility. (d) Progressive muscular dystrophy or atrophy. This condi- tion can result in the inability to perform functions as a mem- ber due to limitations of strength and/or balance. (e) Epileptic conditions. After a provoked seizure, with the precipitant identified and alleviated, with subsequent normal C-T or MRI scan, normal EEG, normal neurological exam, free of recurrence without medication for one ,year, and with defin- itive statement from a qualified neurological specialist, a mem- ber can be cleared to return to duty, A-3-13-3 Category B medical conditions of a neurological nature include the following (a) Congenital malformations (that is, severe vascular mal- formations that interfere with the ability to wear protective equipment) Congenital malformations can result in the inability to properly wear protective equipment. (b) Migraine (that is, recurrent, with impairment uncon- trolled). Migraines can result in Frequent episodes of pain or the inability to perform work. Zrka Edition 1382-18 MFDt(7_\L REh)LIREME`iTS FOR FIRE FWAITERS AND INFO RMATION FOR FIRE DFIVAR17MEVT PIMAr:L\N7 (c) Clinical disorders with paresis, paralvsis, dyscoordina- tion, deformia•, abnormal motor activitc, abnormality ofsema- tion, or complaint of pain (progressive or severe). These disorders are progressive illnesses leading to functional impairment. Tlhev can result in the inability to perform func- tions as a member due to limitations of strength, flexibility, or balance. (d) Subarachnoid or intracerebral hemorrhage, verified either clinically or by laboratory studies. except for those cor- rected with verification by laboratory studies and report of treating phvsician. Subarachnoid or intracerebral hemor- rhage is a progresmve illness leading to functional impair- ment. This illness can result in the potential for sudden incapacitation. (e) abnormalities from recent head injury. such as severe cerebral contusion or concussion. The abnormalities can result in the potential for sudden incapacitation. (t) .any other neurological condition that results in a per- son not being able to perform as a member. A-3-14.2 Cateoory B medical conditions of the skin include the following: (al Acne or inflammatory skin disease (if condition pre- cludes good 6t of protective equipment, such as SCBA Face piece, or prevents shaving). Acne or inflammatory skin disease can result in the inability to properly wear protective equipment- (b) Eczema (if broken skin results in impairment from infections or pain or interferes with seal between skin and per- sonal protective equipment). Eczema can result in frequent episodes of pain or the inability to perform work. (c) Any other dermatologic condition that results in the person not being able to perform as a member. A-3-15.1 Category A medical conditions of blood and blood - forming organs includes the following: (a) Hemorrhagic states requiring replacement therapy (for example, von Willebrand's disease, thromboeytopenia, hemophilia). These hemorrhagic states can result in frequent episodes of pain or the inability to perform work. (b) Sickle cell disease (homozygous). Sickle cell disease can result in frequent episodes of pain or the inability to per- form work and the potential for sudden incapacitation. A445.2 Category B medical conditions of blood and blood - forming organs include the following - (a) Anemia (in cases that require regular transfusions). Anemia can result in frequent episodes of pain or the inability to perform work. Anemia is a progressive illness leading to functional impairment. (b) Leukopenia (where chronic and indicative of serious illness). Leukopenia is a progressive illness leading to func- tional impairment. (c) Polycythemia very (where severe, requiring treat- ment). Polycythemia vera can result in frequent episodes of pain or the inability to perform work and the potential for sud- den Incapacitation. (d) Splenomegaly (where the spleen is susceptible to rup- ture from blunt trauma). Splenomegaly can result in the potential for sudden incapacitation. (e) History of thromboembolic disease (that is, more than one episode or an underlying condition). A history of rhromboembolic disease can result in the potential for sud- den incapacitation. 2000 Edition (f) any other hematological condition that results in a person not being able to perform as a member. A-3-16.l Category A medical conditions of endocrine and metabolic disorders include diabetes mellitus that is treated with insulin or an oral hypoglycemic agent and that includes a history of one or more episodes of incapacitating hvpoghce- mia. Diabetes mellitus can result in the potential for sudden incapacitation. A-3-16.2 Category B medical conditions of endocrine and metabolic disorders includes the following: (a) Diseases of the adrenal gland, pituitary ,land. parathv- roid gland, or thyroid gland of clinical significance (that is, symptomatic and poorly controlled). These diseases can result in frequent episodes of pain, the inability to perform work, and the potential for sudden incapacitation. (b) Nutritional deficiency disease or metabolic disorder (where clinically significant and not correctable by replace- ment therapy or other medication). Nutritional deficiency dis- ease or metabolic disorder can result in frequent episodes of pain or the inability to perform work. (c) Diabetes mellitus requiring treatment with insulin or oral hypoglycemic agent. Diabetes mellitus can result in epi- sodes of pain or inability to perform work. It is a progressive illness leading to functional impairment and can result in the potential for sudden incapacitation. (d) Any other endocrine or metabolic condition that results in a person not being able to perform as a member. A-3.17.2 Category B medical conditions of systemic diseases and miscellaneous conditions include the following: (a) Connective tissue disease, such as dermatomyositis. lupus erythematosus, scleroderma, and rheumatoid arthri- tis (where manifested by systemic impairment or limitations of motion) . These connective tissue diseases are progressive illnesses leading to functional impairment and the inability to function as a member due to limitations of strength or flexibility. (b) Residuals from past thermal injury (for example, frost- bite resulting in significant symptomatic discomfort). Residu- als from past thermal injury may result in the inability to perform functions as a member due to limitations of strength, endurance, or flexibility. (c) Documented evidence of a predisposition to heat stress with recurrent episodes or resulting residual injury. A predisposition to heat stress can result in the potential for sud- den incapacitation and the inability to perform functions as a member due to limitations of endurance. (d) Any other systemic condition that results in a person not being able to perform as a member. A 3-18.2 Categon, B medical conditions of tumors and malig- nant diseases can include the following: (a) The medical evaluation of any pet -son with malignant disease that is newly diagnosed, untreated, or currently being treated will be deferred. Any person with treated malignant disease should be evalu- ated based on that person's current physical condition and on the likelihood of that person's disease to recur or progress. (b) Any other tumor or similar condition that results in a person not being able to perform as a member. APPENDtt k A-3-19.2 Category B medical conditions of a psychiatric nature include the following: (a) Any person with a history of a psychiatric condition or substance abuse problem should be evaluated based on that person's current condition. Psychiatric conditions and sub- stance abuse problems can result in frequent episodes of pin or the inability to perform work and the potential for sudden incapacitation_ These conditions are progressive illnesses lead- ing to functional impairment. (b) Any other psychiatric condition that results in a person not being able to perform as a member. A320.2 Category B medical conditions concerning chemi- cals, drugs, and medications include the following-. (a) Anticoagulant agents such as coumadin can be permit- ted if the anticoagulated state is controlled such that the pro - thrombin time or INR has been in the therapeutic range on a stable medical regimen for at least one month and that no other coexisting conditions would either contribute to a bleeding diathesis or by themselves preclude certification for full duty. Anticoagulant agents can result in frequent episodes of pain or the inability to perform work, as well as the potential for sudden incapacitation. (b) Cardiovascular agents (for example, antihypertensives) can result in frequent episodes of pain or the inability to per- form work, as well as the potential for sudden incapacitation. (c) The use of narcotics can result in frequent episodes of pain or the inability to perform work, as well as the potential for sudden incapacitation. (d) The use of sedative-hypno tics can result in frequent episodes of pain or the inability to perform work, as well as the potential for sudden incapacitation. (e) The use of stimulants can result in frequent episodes of pain or the inability to perform work, as weU as the potential for sudden incapacitation. (f) The use of psychoactive agents can result in frequent episodes of pain or the inability to perform work, as well as the potential for sudden incapacitation. (9) The use of steroids can result in frequent episodes of pain or the inability to perform work. (h) Any other chemical, drug, or medication that results in a person not being able to perform as a member is included in this group. A-4-2.1 Physicians who care for members need to be familiar and keep up-to-date with the most current recommendations for post -exposure prophylaxis ( PEP) for bloodborne patio- gen (BBP) exposures. Also there should be a written protocol for dealing with members who present with BBP exposures. This should be based on the following elements: (1) Fact sheet that explains in lay language the risks of infec- tion, the various prophylactic and therapeutic options, the testing and follow-up that will be needed and recom- mendations for personal behavior (i.e., safe sex, blood donation, and so forth) following an exposure. (2) Classification table to determine the exposure type and recommendation for prophyla-xis. Current recommenda- tions of U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and Public Health Services. (3) Listing of testing to be done on exposed member, includ- ing the following: 1582-19 a. HIV b. Hepatitis B surface Antibody (HBsAb), if not previ, ously known to be positive c. Hepatitis B surface Antigen (HBsAg), if not previously known to be positive HBsAb d. Hepatitis C Antibody (HCAb) e. If HIV prophylaxis is to be given, the following tests should be done: I. CBC 2. Glucose, renal and hepatic chemical function 3. Pregnancy test for females (4) Listing of testing to be done on source patient, including the following: a. HIV b. HBsAg c. HCAb (5) If source is available, interview for HIV, HepB, and HepC risk/ status. (6) Determination of risk and need for PEP (7) Member counseling regarding PEP medication(s) and side effects of treatment. A printed fact sheet should be available for the member to review. (9) If PEP prophylaxis is to be given, it should be done as soon as possible after the incident, preferably within 2 hours. (9) Members on prophylaxis need to be followed (preferably by an ID specialist) for the duration of their treatment. (10) Assessment of tetanus status and administration of dT booster, if appropriate G 1) Assess HepB status a. If previously immunized with a positive post -immuni- zation titer, no further treatment is needed. b. If previously immunized, titer was negative, and source is HBsAg positive or high risk, give Hepatitis B Immune Globulin (HBIG) as soon as possible — pref- erably within 24 hours — and a dose of Hepatitis B vaccine. c. If previously immunized and titer is unknown, draw titer. 1. If Liter is positive, no further treatment is needed, 2. If titer is negative and source is HBsAg positive or high risk, then give Hepatitis B Immune Globulin (HBIG) as soon as possible — preferably within 24 hours — and a dose of Hepatitis B vaccine. d. If previously immunized with negative Liter and revac- cinated with a negative titer, give HBIG immediately and a second dose 1 month later. e. If never immunized, give HBIG and begin Hepatitis B vaccine series. (12) Follow-up instructions should include the following. a. Adverse events and side effects of PEP b. Signs and symptoms of retrovirsl illness (fever, aden- opathy, rash) c. Appointments for follow-up blood work, including the following: 1. HlVat 6 weeks, 3 months, and 6 months 2. HB,,Ab and/or HCAb at 6 weeks, 3 months, and 6 months, if source is HepB and/or HepC positive 3. Every other week CBC, renal and liver function, if receiving PEP 2000 Edition 1582-" 0 MEDICkL REQUIRENIENT5 FOR FIRE FIGFiTERS.IND iNFOR.AkVION FOR FIRE DEPAIUMENT P1RSfCf.y`'S A-4-2.2 Post -exposure prophylaxis may also be indicated for the following diseases: (1) Diphtheria (2) Hepatitis A (3) Meningitis (4) Per iissis (5) Rabies (6) Vancella Zoster A- -3.1 An annual TB program should include the following: ( I ) Documentation of two-step purified protein dericati%-e (PPD) prior to this PPD or a 0-mm PPD within the past I year. (`_') Placement of PPD and reading by a trained, designated reader within 48 hours to 72 hours of placement. Mem- bers with a history of positive PPD should fill out a giies- tionnaire. (3) PPD results should be documented in millimeters (mm). A test with no skin reaction should be recorded as 0 min (4) A PPD skin test will be considered positive if the following conditions are present: a. Greater than 5 mm in someone who is immunosup- pressed b. Greater than 10 mm in someone with a normal immune system who is at risk for conversion due to an exposure c. Greater than 10 mm increase from previous reading (5) If PPD is positive (conversion), the following steps should be taken: a. Fill out questionnaire b. Obtain chest x-ray c. Evaluate for active disease d. Evaluate for preventative therapy (6) If active disease is diagnosed, the member has to be removed from any duty until she/he has been deter- mined to be noninfectious. This will occur when ade- quate therapy has been instituted, the cough has resolved, and 3 consecutive sputum smears for acid -fast bacillus (AFB) on different days are negative. A-4-3.2 In the event of an exposure to TB, the following steps should be taken: (1), Member should receive a PPD within 14 days of expo- sure. Members with a history of positive PPD should fill out a TB questionnaire. (2) Repeat PPD or questionnaire should be done 6 weeks to 12 weeks after the first. (3) If PPD is positive (conversion) or questionnaire is posi- tive, proceed as per (5) and (6) of A-1-3.1. A-4-4 29 C:FR 1910.1030 requires that members be offered Hep- atitis B immunization at no cost to the member. Members who choose to decline the offer of this immunization are required to sign a written declination. The declination becomes part of a member's confidential health data base as specified in Section r3-4 of NFPA 1500, .Standard on Fire Department Oreupattonal.Saferp and Health Program. Members are allowed to recant at any time and receive offered immunizations. A-5-1.1 Having a preplanned rehabilitation program that is applicable to most incident types is essential for the health and safety of members. This program should cudine an ongoing rehabilitation for simple or short -duration incidents as well as a process to transition into the rehabilitation needs of a large 2000 Edition or long -duration incident. Medical evaluation and treatment in the on -scene rehabilitation area should be conducted according to emergency medical service (EMS) protocols developed by the fire department in consultation with the fire department phvsieian and the EMS medical director. If advanced life support (,1.LS) personnel are available, this level of E.NIS care is preferred. A-5-1.2 Weather factors during emergency incidents can impact severehon the safety and health of members, who are operating during extremes of heat or cold. Where these fac- tors combine with longduradon incidents or situations that require heavy exertion. the risks to members increase rapidly. The tire department should develop procedures, in consulta- tion with the fire department physician, to provide relief from adverse climatic conditions. The following are typical rehabilitation considerations for operations during hot weather extremes: (1) Moving fatigued or unassigned members away from the hazardous area of the incident (2) Removing personal protective equipment (3) Ensuring that personnel are out of direct sunlight (4) Ensuring that there is adequate air movement over per- sonnel, either naturally or mechanically (5) Providing members with fluid replenishment, especially water (6) Providing medical evaluation for personnel showing swans or symptoms of heat exhaustion or heat stroke The following are typical rehabilitation considerations for operations during cold weather extremes: (1) Moving fatigued or unassigned members away from the hazardous area of the incident (2) Providing shelter from wind and temperature extremes (3) Providing members with fluid replenishment, especially water (4) Providing medical evaluation for members showing signs or symptoms of frostbite, hypothermia, or other cold - related injury A-5-2.2 The assignment of an ambulance or other support crew to the rehabilitation function is essential during long - duration or heavy -exertion incident operations. This crewcan assist with rehabilitation functions as well as be available to provide immediate basic life support needs for members. Advanced life support (paramedic) level of evaluation and treatment has to be available quickly, however, to ensure the proper level of care. The medical staff has to have an assigned medical director. This can be an on -scene physician such as a fire department physician, a remote physician at a base hospital, or a central medical direction facility. A-5-3.2 For major incidents or escalating incidents, medical control can be established by the fire department physician or medical director at the incident scene. Burn Injury. When a member suffers a burn injury, he or she should be evaluated as to the extent of injury. First -degree burns can be treated on scene, and the member may continue duty. Second-degree burns should be evaluated by a physician familiar with burns, such as an emergency department physi- cian, a member of a burn unit, or a fire department physician. Second-degree burns and higher are conditions that demand that the member be removed from emergency response duty. After the bums have healed to the extent that there is minimal risk for entry into the member's body of body fluids and chem- APPENDIX R icals encountered during; re),*ular duties, he or she can return to full duty. The .krnerican Bum Aosociation has criteria for referral to a burn center. They are second- and third-degree horns with characteristics as follows: (1) Exceeding 20 percent body surface area (BSA) ( 2) Exceeding 10 percent BSA for age under 10 or over 50 (3) Any third-degree burn over 5 percent BSA (4) Involving hands, fret, face, perineum, enitolia, or major joints (5) Circumferential involving extremities or chest (h) Caused by contact with chemicals, electricity, or lightning (7) Coupled with smoke inhalation injury (3) Associated with multiple trauma (9) Involving patients with preexisting significant medical illness ,Musculnskelrtal Sprains. Strains and sprains are among the most common member injuries. When they occur during pen- ods when circulating catecholamines are ht,h. such as on the fireground, the injured member might underestimate the severity of the injury. Under such conditions, he or she might continue working and worsen the injury. Evaluation of these type of injuries on the fireground can be difficult. The injury might worsen with time due to swelling, muscle spasm, and increased pain perception after the emer- gency call is over. Any acute injury that leads to swelling or results in more than a trivial limitation ofmotion should prob- ably be evaluated by a physician. .Smoke Inhalation- Smoke inhalation is fortunately becoming less common, due to the use of self�_ontained breathing appa- ramis. A member with smoke inhalation should be treated with 100 percent oxygen and transported to an emergency depart- ment Burns involving greater than 15 percent of body surface area, facial burns, singed hair, and airway soot are associated with more severe airway bums. Lower airway injury can be associated with carbonaceous sputum, wheezing, tales, rhon- chi, and chest pain, Pulmonary function tests can reveal a decrease in forced expiratory volume in one second (FEVI). A chest radiograph may disclose infiltrates or atelectasis. Hypoxemia may be seen on arterial blood gas analysis. A nor- mal chest radiograph and normal arterial blood gas results do not, however, rule out significant smoke inhalation injury. Endotracheal intubation should be performed if there is central nervous system,suidor, h poxemia (POz less than 60), hypercarbia (PCO� greater than 50), full -thickness bums of the face or neck, airway or pulmonary edema, or inability to handle secretions. Positive end —expiratory pressure (PEEP) should be used if hypoxemia persists despite intubation and administration of IW percent oxygen. Inhaled beta-agonists and anticholinergir_s can be used for bronchospasm. Systemic corticosteroids are not recommended for pneumonitis or pul- monary edema. Antibiotics may be needed if sputum gram stain and culture with fever and leukocytosis suggest the pres- ence of a bacterial pneumonia. Dimon Abrmber Certainly the scenario involving the discovery of an unconscious member is one that is difficult to manage given the psychological responses of all involved. Of course, the first priority is the safe removal of the victim from the ha2- ardous area. Then the Airway, Bleeding, Cardiac (ABCs) are carried out and a secondary surrey performed. Transport to a hospital should be expedited. Any unconscious member should be treated with 100 per- cent oxygen, since carbon monoxide poisoning is common and cyanide poisoning possible as secondary effects of smoke r CQ.) .,, inhalation. At the enurgencv department, the victim should have an arterial carboxvhrmoglobiu deterrnincd and should be evaluated for possible c}anidr toriciry If cyanide poisoning is suspected, treatment with a ,Nanide antidote kit should be initiated. Since inducing methemoglobinemia in a patient with an elevated carboxvhernotzlobin level mac further impair oxygen deliserv, only sodium thiosulfate should be given rni_ tiallv. If treatment with hyperbanc oxvgr.n is ,carted, nitrites may he used. A-i-4.3 Items that can assist in limiting temperature stress in cold environments include heat, blankets, and protection from the wind. For hot weather, items ihould include adequate shade, tuns, air-conditioning, and misting sv5iems. Food and hydration needs include water and oral fluids, food, broth. and fntit.Also, for hydration, a 50%50 mixture of water and an electrolvte replacement drink can be provided. Medical equipment should include blood pressure cliffs, stethoscopes. oxygen, cardiac monitors, thermometers, and intravenous fluid and supplies. -5.4.4 The incident commander should consider the cir- cumstances of each incident and make suitable provisions for rest and rehabilitation of members operating at the incident scene. For example, when members consume air from two SCBA air cylinders (two-etilinder rule), they should be assigned to rehab. A54.5 The measurement of the pulse rate has been used by some fire departments in assessing members during rehabilita- iion. A persistendy elevated pulse could be a sign of excessive stress on the body due to dehydration, heat stress, exhaustion, or cardiopulmonary disease. The use of a pulse rate has not been studied in a manner that allows strict medical protocol to be recommended. The pulse rate combined with the remain- der of the clinical evaluation of the member may be used to determine if the member can return to operations. Appendix B Information for Fire Department Physicians This appendix is not a pan of the requirements of this A7;pi doc- ument but is included for informational purposes only. B-I Occupational Safety and Health Problems for Members. B-I.I General. Fire fighting and emergency response are very difficult jobs. People in these jobs perform functions that are physically and psychologically very demanding. These functions are often performed under very difficult conditions. (.See Appendix C.) B-1.2 Physical Load. Studies have shown that fire -fighting functions require working at near, maximal heart rates for pro- longed periods of time. Heavy protective equipment (includ- ing respirators) and the heat from the fire contribute to this physical load. B-1.3 Toxic Substances. Members and emergency response personnel also are exposed to many toxic substances during their work- Carbon monoxide is the most common contami- nant studies have shown individual exposures that are as high as 5000 ppm during actual fires. Other significant exposures common during fires include cyanide, acrolein, hydrogen chloride, nitrogen dioxide, and benzene. The burning of plas- tics and other synthetic materials can expose members to other toxic materials, such as isocyanates and nirrosamines. Hazardous materials incidents can involve exposures to many 2000 Edilion 1582-22 MEDIGIL REQfARE`IENT.'i FOIL FIRE FIG IfTCRS .\ND IVFt)R\L\I'ION Fog FIRE DI:P \RTNIENT PI Ptti1C(.\Nti other toxic materials..AJthough the use of respirators helps to reduce exposures. mechanical, environmental, and behav- ioral factors can limit their use during all phases of a tire The available health data on members are limited. �b'hlle the protection for members has improved over the last several years, exposures might be changing due to the introduction of more Wrltiteuc materials. Given the delay between expOstl(e and onset. (that is, latency) of many occupational illnesses, current or past health Studies of members might not retlect future health nsks. These limitations should be recognized when reviewing the available snldies. B-1.4 Increased Risk of Injury and Disease. Available data indicate that members have increased risk for injuries, ptll- monary disease, cardiovascular disease, cancer, and noise- indilced hearing loss. The- increased risk for injuries is expected, given the demands and circumstances of this work. Fatalities and serious injuries from burns or other fire -scene hazards can occur. The risk for respiratory disease occurs due to the respira- tor• damage caused by many of the components of fire smoke (for example, particulate, acrolein, nitrogen oxides, and so on.) Acute reductions in pulmonary function and even hvpox- emia are not uncommon after fires, even in asyrriptomatic members. Permanent damage from smoke inhalation has also been reported. Studies of chronic pulmonary changes from fire fighting have not had consistent results. Some follow-up studies have shown a greater rate of decline in pulmonary function among members over Lime, while others have not been able to detect this change. Increased use of protective equipment and job selection factors (it[ members transferring to other dudes) could account for these inconsistent findings. The strenuous work demands of fire fighting combined with exposures to carbon monoxide and other toxic sub- stances can increase the risk for cardiovascular disease among members. Acute respiratory changes also can stress the cardiovascular system. This increased cardiovascular dis- ease risk has been documented even in some mortality stud- ies, despite the job selection factors that tend to mask any increase when compared to the general population. Other studies have not detected this risk. Certainly, the combina- tion of the physical stress of fire fighting and exposures for a person with preexisting coronary heart disease would be expected to increase the risk of a myocardial infarction or other acute event. However, the degree of this acute risk and whether fire fighting also contributes to the development of coronary heart disease is uncertain. increased cancer risk for members has been found in sev- eral recent studies. While not totally consistent, these studies generally show an increased risk of brain cancer, (gastrointes- unal cancersi colon cancer, prostate cancer, lymphoma, and leukemia among members in many different parts of the world. increased incidence of other cancer sites has also been shown in some studies. Several studies are currently under way to further evaluate this risk. Noise -induced hearing loss has now been documented in several studies of members. Members might also be at risk from other specific exposures including infectious diseases and liver, kidney, or neurological damage from exposure to specific chemicals. 2000 Edrtron B-2 Guidance for Medical Evaluations. B-2.1 Preplacement and Baseline Medical Evaluations. Preplacement medical evaluations assess au individual's health status before assignment to a position. The purpose of the eyaklatlon is to ascertain whether the indmclual has am health condition that prevents him or her From performing the fob. incAiding the ability to wear protective equipment required for the job. The e-rtluation should also identify any health problems that could be substantial[v a¢gravated by the physical demands and working conditions. Baseline medical information concerning the applicants health status can then be compared to subsequent e-.aluation result for the purpose of determining whether the individual has any significant health trends that can be occupationally related. Two apes of information are essential for a medical Pre - placement evaluation of those performing member dudes. First, the physician most understand the working conditions and physical demands of this occupation. ,appendix C pro- vides a list of the emironmental factors encountered in fire fighting and emergency response. The physician also should obtain additional information from the fire department regarding specific job duties and task lists (if the fire depart- ment has conducted a validation study or job anahsis) and should be familiar with the organization of the fire depart- ment. For the evaluation of some medical conditions, the phy- sician will need to obtain further information about specific job duties in order to make a determination. This might require on -site inspections and consultation with fire depart- ment personnel. Second, the physician needs to have accurate information about the person's disease or medical condition, the func- uonal limitations associated with that condition, and an understanding of how physical demands and working condi- tions would impact on that condition. An accurate diagnosis is often the key factor in determining the person's capability. For example, different skin diseases can have similar clinical appearances but can markedly differ in their response to envi- ronmental exposures. The physician should also recognize that individual variability can exist between persons with the same clinical condition. Upon completion of the examination, the physician should inform the authority havingjurisdic Lion whether theapplicant is medically qualified to perform as a member. 13-2.2 Periodic Medical Evaluations. The periodic medical evaluation is designed to evaluate the person's continued abil- ity to perform his or her duties and to detect any other signif- icant changes in the condition of his or her health. The latter includes possible job -related changes or abnormalities. Every year, each member will be medically evaluated by the fire department physician. This medical evaluation includes an update on the member's medical history, including any sig- nificant changes, a brief review of symptoms, and a report on any significantjob-related exposures experienced during the past year. Height, weight, visual acuity, and blood pressure are measured and recorded. The extent of the medical evaluation and additional testing will depend on the member's medical condition. A more thorough evaluation, including a medical examina- tion, is conducted on a periodic basis. For individuals less than 30 years of age, the medical evaluation and examination is conducted at least every three years; for those 30 to 39 years of age, at least every two years; and for those 40 years of age or over, every year. This evaluation should include an updated medical and interval history, complete physical examination, vision testing, audiometry, pulmonary function testing. and a CBC, urinalvsis. glucose. BUN. creaunine, liver funcuon tests, and lipid profile. The use of chest x-rays in surveillance activities in the absence of significant exposures, symptoms, or medical find- ings has not been shown to reduce respiratory or other health impairment. Therefore, only preplacement chest x-rays are recommended. .; No firm gtudeline-, for stress electrocardiogm-aphv in asymp tomatic individuals have been developed. There have been problems with false positive results from this testing, especially in younger age groups and in women. in those with one or more risk factors for coronary artery disease, there is probably justification for performing the testing. As well, stress tests are more important in those whose work deals with public safety. 'J9 - Stress tests can be performed using a treadmill, bicycle, or stair climber, as long as the protocol being used gradually increases in workload metabolic equivalent of resting energ expenditure (NIETS). A submaximal test, with the endpoint being the attainment of 85 percent of predicted maximal heart rate (PNIHR), may be performed. Additional informa- tion gained by performing a maximal symptom -limited test might not be worth the additional time, effort, cost, and risk. A reasonable approach is to start periodic treadmill testing on members at age 4). In those with one or more coronary artery disease risk factors (premature family history (less than age 55), hypertension, diabetes mellitus, cigarette smoking, and hypercholesterolemia (total cholesterol greater than 240 or HDLcholesterol less than 35)], testingshould be started by age 35. The frequency of testing should increase with age, but at the minimum the test should be done at least every two years. Testing can also be done as indicated for those with symptoms suggestive of coronary artery disease, as reported in their yearly medical histories or interim reports. Conversely, it is known that even maximal stress testing fre- quently misses cardiac abnormalities seen during actual fire- fighting duties. <— B-2.3 Content of the Medical Evaluation. B-2.3.1 Medical and Occupational History. The medical his- tory should cover the person's known health problems, such as major illnesses, surgeries, medication use, allergies, and so forth. Symptom review is also important for detecting early signs of illness. In addition, a comprehensive medical history should include a personal health history, a family health his- tory, a health habit history, an immunization history, and a reproductive history. An occupational history should also be obtained to collect information about the person's past occu- pational and environmental exposures. B-2.3.2 Medical Examination. The medical examination includes the following organ systems and tests: (1) Vital signs, such as pulse, respiration, blood pressure, and, if indicated. temperature (2) Dermatological (3) Ears, eyes. nose, mouth, throat (4) Cardiovascular (5) Respiratory (6) Gastrointestinal (7) Genitounnary (8) Endocrine and metabolic (9) Musculoskeletal (10) Neurological 158'_-23 (11) Audiometry (12) Visual acuity and peripheral vision testing (t3) Pulmonary function testing (14) Laboratory testing, if indicated (15) Diagnostic imaging, if indicated (16) Electrocardiography. if indicated B-2.3.2.1 UboratoryTests. CBC. biochemical test battery, urinalysis, glucose. BUN, creaunine, liver function tests, and lipid profile. should be conducted for detecting specific ill- nesses as well as developing a baseline for later comparison. B-2.3.2.2 X-rays. A baseline chest x-ray can be helpful for individuals with a history of respiratory health problems or symptoms. For others. it can be useful for later comparison. B-2.3.2.3 Pulmonary Function Testing. Pulmonary function testing can be helpful for individuals with a history of respira- tory health problems and as a baseline for later comparison. A baseline test should be administered by an experienced per- son. Only a spirogram that is technically acceptable and dem- onstrmtes the best efforts by an individual should be used to calculate the forced vital capacity (FVC) and forced expiratory volume in one second (FEV"I). B-2.3.2.4 Audiometry. Audiograms should be performed in an UNSI-approved soundproof booth (ANSI 53.1, .Maximum Permusibh. ,Ambient Noise Levels for.{udiometric Test Rooms) with equipment calibrated to ANSI standards (ANSI 53.6, Specifrca- tian for Audiometers). If a booth is unavailable, the test room sound pressure levels should not exceed those specified in the federal OSH k noise regulations (29 CFR 1910.95). B-2.3.2.5 Electrocardiography. Baseline electrocardiography should be conducted. (Periodic resting electrocardiograms have not been shown to be useful, but may be reasonable as a member's age increases.) B-2.4 Reporting the Results of the Medical Evaluation. All individuals participating in a medical evaluation should be informed ahead of time about the purpose of the medical evaluation and the content of the exam. The results of any medical evaluation are considered to be confidential medi- cal information, subject to customary patient -physician con- fidentiality restrictions. Under most circumstances, results and recommendations arising from the evaluation should be expressed in general terms without specific diagnostic infor- mation. In cases where more specific information is needed in order to make a decision on the status of a candidate or member, a specific consent form releasing that information should be obtained from the candidate or member. Blanket or general 'release of medical information" forms should not be used. In most cases, a simple statement like one of the following will suffice: (a) Based on the results of the preplacement medical eval- uation of December 10, 1996, Jane Doe is (or is NOT) medi- cally certified to engage in training and emergency operations for Anytown Fire Department- (b) Based on the results of the preplacement medical eval- uation of December 10, 1996,John Doe is NOT medically cer- ufted to engage in training and emergency operations for Anytown Fire Department. He has been advised of the medical reasons for this recommendation and of the policies and pro- cedures available to him if he disagrees with the results of the medical evaluation. 20W Edition 15S':-`_' I• NIED(i-.1L REQUIREMENTS FOR FIRE FIGHTEM AND iNFt)R.'�L1TioN FOR FiRL• DEPARTMLNT PF i�Sit (.\V5 B-2.5 Second Opinions. Fire department policies and proce- dures should allow fora medical second opinion when a candi- date or member disagrees with the results or recommendations of a medical examination conducted by the Fire department physician or when the fire department physician is uncertain about the limitations or prognosis of the indiyiduafs condition. Often other physicians will not be familiar with the duties and demands of fire fighting and emergency response. When possi- ble, the fire department physician should help educate the other physician about how the individual's condition could affect or be affected by firefighting If there is still disagreement about the condition or placement recommendation, a third physician (acceptable to both the fire department and the can- didate) can be consulted. B-2-6 Musculoskeletal System. Some of the injuries or prob- Iemti encountered in this system will need functional capacity evaluation to determine fiuiess for duty. Phvsical therapy pro- viders often design tests for employers to determine abilm to perform tasks similar to those required as part of their essen- tial job functions. These tests should be based on direct mea- surements of the actual job functions. These functional capacity evaluations can be especially useful when a member has been cleared for full duty by a physician who is not familiar with the essential job functions of a member. B-3 Specific Medical Conditions. B-3.1 Diabetes Mellitus, The major concern for diabetic members is the risk of becoming hypoglycemic during fire. ground operations or other emergency responses. Both exog- enous insulin and oral hypoglycemic agents can be associated with episodes of hypoglycemia that can rapidly progress from impaired judgment to unconsciousness. The most reliable predictor of hypoglycemia is a history of it. In one study of insulin -dependent adolescents conducted at the Joslin Clinic (Bhatia and Wolfsdorf 1991), all 196 patients experienced hypoglycemia at least once during the two-year observation period. Of these, 15 percent were classified as severe, based on loss of consciousness, seizure, or the clinical need for thera- peutic glucagon or intravenous glucose, It was particularly concerning that 24 percent of hypoglycemic episodes detected by blood glucose monitoring were inapparent to the patients. The probable causes of hypoglycemia were identified in 71 percent of cases, and the most common were strenuous exercise and skipped meals or snacks. Both of these precipi- tants are likely to occur in emergency responders, especially Fire service personnel. In addition to accelerating glucose uti- lization, strenuous exercise increases insulin sensitivity (Wasserman and Sinman 1994). With the tighter glycemic control that is now known to decrease and delay onset of dia- betic complications, there is a concomitantly increased likeli- hood of exercise -induced hypoglycemia (Wasserman and Sinman 1994). Insulin is clearly associated with a much higher risk of symptomatic hypoglycemia than are oral agents. In the absence of a history of incapacitating hypoglycemic episodes, and with close medical monitoring, there is probably no rea- son to exclude members who are taking oral hypoglycemic agents, as long as they have stable weights, diets, and renal function. Although the Americans with Disabilities Act (Public Law 101.336 1990) does not appear to require each diabetic patient to be evaluated for fitness for duty individually, there is some case law that disallowed blanket exclusion of insulin - dependent diabetics from public safety positions (Fire & Police Personnel Reporter 1994). The Federal Aviation 2000 Edition Administration (l l (.FR67.1316 199 i) dues not grant medical certificates to dcibetics treated with insulin and severely limits those on oral hypoglycemic agents. B-3.2 Asthma and Reactive Airways Disease, The diagnosis of asthma and related airway hyperactivity disorder~ is often confounded by definitional is,ues. For the purposes of member certification, a variety of airway disorders that meet the following criteria can be included. Asthma is a chronic inflammatory disorder of the airways. In suscepti- ble individuals, this inflammation causes symptoms that are usually associated with widespread but variable airflow obstruction that is often reversible, either spontaneously or with treatment, and causes an associated increase in airway responsiveness to a variety of stimuli. Since asthma is a highly prevalent disease, a number of member applicants will require special evaluation. Combus- tion products, exercise, and cold air are all potent provokers of an asthma attack. Some of these exposures are unavoidable, even with SCBA use. If a candidate has a diagnosis or symp- toms consistent with an asthma -like disease, many factors will need to be considered. An asthma attack duringa suppression activity could harm the member, his fellow members, or a member of the public. The following factors can be used to help in certification: (1) Persistence of airway obstruction between attacks (as measured by spirometry) (2) Need and frequency of steroid and bronchodilator use (frequent bronchodilator use suggests persistent airway hyperactivity) (3) Usual type of triggers in the applicant (allergic, infec- tious, exercise -induced, etc.) (4) History of hospitalization, emergency room, or urgent treatment (5) Length of time between attacks (6) Nocturnal symptoms and other estimates of airway insta- bility Moderate asthma or worse could disqualify an individual for member duties. Unknown factors such as the suppression of airway hyperactivity with anti-inflammatory medications to reduce the possibility of a sudden or severe attack are under investigation and could modify current suggestions. B-3.3 Heart Disease. The medical conditions relating to the cardiovascular system have been reviewed since the previous edition (1997) of this document. The task forces at the Bethesda Conference published recommendations for ath- letes competing with cardiovascular disease in theJourrialofthe American College of Cardiology, in October 1994. The analysis used by the task force has relevance to the evaluation of mem- bers with cardiovascular disease. Fire -fighting activities have a high static component (i.e., inducing predominantly an increase in blood pressure) and a moderate to high dynamic component (i.e., inducing predominantly an increase in heart rate). Sports with a similar set of demands include wrestling, body building, and boxing. Recommendations made by the task force with respect to athletic activities that have these physical demands (high static, moderate dynamic) have been followed in this document. B-3.4 Reproductive- Exposures in the Fire -fighting environ- ment can cause adverse reproductive effects for both males and females. Medical evidence exists to indicate that chemical exposure, heat, noise, and physical exertion can affect various endpoints of reproductive health including fertility, fetal loss, VVE` DID 13 and growth parameters of the offspring..Ul candidate, and members should be educated about these risks and about the need to take appropnate steps to limit dietr exposures. Also. there could be some situations where a male or female member is attempting to conceive a child and is hiving difftculn•. In these situations, where a complete medical evalri- ation has not identifier{ another cause for this inferutirv, tem. porar+:usignment on a voluntary basis ro alternative dtta or a leave of absence should be considered. Medical evidence exisr--s that certain toxic substances or con- ditions that are present in the fire -Fighting environment are damserous to the safet< and well-being of the fetus. Therefore. it is important to educate all members about these risks and the reasons for recommending that pregnant members restrict their tire -suppression activities. For example. there is good evi- dence that the fetus is especially sensiuve to carbon monoxide. a known si,pificant component of tine smoke..lthough the use of SCBA is assumed to be protective, sometimes ouch equipment is not used throughout a fire suppression or haz- ardous materials incident. The use, of such equipment also increases other fetal stressors, such as exertion and heat. Other concerns are those involving physical work. Prolonged stand- ing, heavy lifting, and exposures to temperature extremes and humidity have been related to an increase of preterm and low birth weight infants. Because the fetus should be protected from these exposures at the earliest possible time, the member who might be pregnant should obtain early pregnancy testing. Recognizing potential risks to the fetus from the fire -fighting environment is a relatively recent event, and manv members might not be aware ofthese risks. Based on a recent U.S. Supreme Court decision (Inter na- tional Union et al. v. Johnson Controls. Inc., 59 U.S.LAV 4209, [arch 20. 1991). the ability to perform as a member is to be the basis for the medical certification without consideration of health risks to the fetus. However, the pregnant member should be counseled on the potential risks to her fetus due to her exposures during fire -fighting duties. Any member who becomes pregnant should be offered the opportunity at any time during the pregnancy to be voluntar- ilv removed from tire -fighting duties and from other duties involving the hazards or physical stress that might endanger the fetus. If practical, the member should be offered voluntary reassignment to an alternative position. At such time as the pregnant member can no longer be medically certified as being capable of performing fire -fighting duties, the member should be reassigned to other duties. At such time as the mem- ber is no longer pregnant, the member should be reinstated to the position held prior to being pregnant. Nursing mem hers should also be advised about the potential exposures to their infants. B-3.5 Noise -induced Hearing Loss. This category can pose difficulties because a high percentage of current members have noise -induced hearing loss due to their exposures as members. Implementation of hearing conservation programs and programs to reduce noise exposures should lead to a decrease in the prevalence of this condition in the future. &3.6 Seizures and Epilepsy. It is important to distinguish between a history of seizures and epilepsy. As much as It) per- cent of the population will experience at least one seizure in a lifetime, whereas less than l percent of the population qualities for a diagnosis of epilepsy (Hauser and Hesdortler 1990). Manv conditions producing seizures in the pediatric age group are known to remit prior to adulthood, and many adults sustain a 159°-"S reactive sciiairc that caul he attributed to a rcversiblc, rinderiv. ing precipim,it. These circumstances do not ncccsarily repre- s(-nt an ongoin, risk ofhwlden. unpredictable incapacitation ,) f a member. If .1 member has a ,in -;le ieizure, a clear precipitant not associated with central nervous svtem dams e is identified and eliminated. and die individual has no recurrence over the• ensutn, year, dien he or she is prohahly not more likely to h_ne another ieizitre than die rest of the general popitlation (Spun. cer 191 51, ylo,t fire department phvsicium till want a grialitl,,t nemolo st to verity that ati individual with a histoitiv of seizures does not, in tact, have epilrp.w. Epilepsy is rii.t;no,ed by the presence of -unprovoked, recurrent seizures — paroxysmal disorders of the central ner. vous system characterized by an abnormal cerebral neuronal discharge with or without loss of consciousness' (Ca-scino 1994). Treatment of patients with epilepsy is onlvvariablvsuc- cessful, with roughty 40 percent of patients attaining remission on anti-,:onyulsant therapy (Hatser and Hesdortfer 1990: Spencer 1595). Remission is defined as five years without recurrence of seizure activin• (A-nnegers, Hattser, and Elve• back 1979). Further complicating the fitness-fordury issue is the fact that only 30 percent of patients who achieve remission do so without toxic side effects of the anti-convlilsant drug (Caucino 1994). Partial, simple epilepsy, or recurrent seizures that do not impair consciousness, are felt to be a disqualifying condition because of the uncertainir regarding how much of the brain might be involved, and the risk of propagation to other regions of the brain, particularly in the highly epiteptogenic environment of the tireground (Spencer 1995). This standard is somewhat more liberal than that promul- gated by the Federal ,aviation Administration of the U.S. Department of Transportation for aircraft pilots (14 CFR 67.1316 1995). All epileptics, regardless of therapeutic success are denied first-, second or third-class medical certificates, except under the provisions of 14 CFR67.19. "Special issue of Medical Certificates." R4 References. Annegers, J. F., W. A. Hauser, and L. R. Elveback. 1979. "Remission of Seizures and Relapse in Patients with Epilepsy," Epilepsia 20:729. Bhatia, V., and J. I. Wolfsdorf. 1991. "Severe Hypoglycemia in Youth with insulin -Dependent Diabetes Mellitus: Fre- quency and Causative Factors" Pediatrics, 88:1137. Brunacini, Alan. Fireground Command. National Fire Protec- tion Association, 1985. Cascino, G. D. 1994. Epi&psy: Contemporary Perspectives on Evillualian and Treatment, Mayo Clinic Proceedings 69:1199. -Emergency Incident Rehabilitation," United States Fire Administration (FA#112). Fire & Police Personnel Reporter„November 199.4, p. 169. Hauser, W. A., and D. C. Hesdorffer. 1990. "Epilepsy: Fre- quency. Causes and Consequences." New York: Demos. National Fire incident Reporting System (NFiRS) data base. NFPA 1591, Standard for Firr Department .Safety Of icer, 1997 edition. Public Law 101.336, 1990. Tide I - Employment. Spencer, S., Personal Communication, 1995. (Spencer is professor of neurology and director of the Clinical Epilepsy and Electrophysiologic Monitoring Services at Yale University School of Medicine.) Title 14, Cale fire Federal R, q"Iations. Part 1910.1000, Sub- parts 13-I6. ".•air Contaminants." NOO Edition 1382-216 >iEDIG\L REQL IR.E.ME• YTS FOR FIRL• FIGHTERS \ND iN'FORXUT10N FOR FiRE DEPAR i\ICNT P14N}iCLtiN5 "Toxic smoke inhalation: Cyanide poisoning in fire vic- tims." Jones, J. et at.. Arnencan Journal of Fmergmry Medicine 3.317, 1987 Wasserman, D. H.. and B. Sinman. 1991. "Exercise in Indi- viduals with IDDM." Diahear Carr, 17.92 1. Appendix C Essential Structural Fire -Fighting Functions T[rs appendix s nut a part of the requirements of thts .v7P.1 Gx wnvnt but 1.5 rnt hided for infinmational purposes anly. C-1 The medical requirements in this standard were based on in-depth consideration of essential structural fire-fighung functions. These essential functions are what members are ex- pected to perform at emergency incidents and are derived from the performance objectives stated in NFPA 1001. Stan- dard for Firr Fi�rhtrr Pro�es.siunal ewrlifi<'atirnrs. Essential functions are performed in and affected by- the following environmental factors: (1) Operating both as a member of a team and indepen- dendy at incidents of uncertain duration (`') Spending extensive time outside exposed to the elements (3) Tolerating extreme fluctuations in temperature while per- forming dudes; fire fighters are required to perform phys- ically demanding work in hot (up to 4007), humid (up to too percent) atmospheres while wearing equipment that significandy impairs body -cooling mechanisms. (4) Experiencing frequent transidon from hot to cold and from humid to dry atmospheres (3) Working in wet, icy, or muddy areas (6) Performing a variety of tasks on slippery, hazardous sur- faces such as on rooftops or from ladders (7) Working in areas where sustaining traumatic or thermal injuries is possible (8) Facing exposure to carcinogenic dusts such as asbestos, toxic substances such as hydrogen cyanide, acids, carbon monoxide, or organic solvents, either through inhalation or skin contact (9) Facing exposure to infectious agents such as Hepatitis B or HIV (10) Wearing personal protective equipment that weighs approximately 50 lb while performing fire -fighting tasks (11) Performing physically demanding; work while wearing pos- itive -pressure breathing equipment with 1.5 in. of water column resistance to exhalation at a flow of 40 L/min (12) Performing complex tasks during life -threatening emergencies (13) Working for long periods of time, requiring sustained physical activity and intense concentration (1 1) Facing life-ondeath decisions during emergency conditions ( l5) Being exposed to grotesque sights and smells associated with major trauma and burn victims (16) Making rapid transitions from rest to near -maximal exer- tion without warm-up periods (17) Operating in environments of high noise, poor visibility, limited mobility; at heights; and in enclosed or confined spaces (N) Using manual and power tools in the performance of dudes (19) Relying on senses of sight, hearing, smell, and touch to help determine the nature of the emergency, to maintain personal safety, and to make critical decisions in a con- fused, chaotic, and potentially life -threatening environ- ment throughout the duration of the operation 2000 Edition Appendix D Guide for Fire Department Administrators Thu abprndix is not a part of the, reguirrmerrtt of 'his .\,7P-{ elwr- ument but is included for rnprmational purpnvrs anL, D-I Legal Considerations in .applying the Standard. The con- sideration of an application or continued employment of a mem- ber hued on medical or physical performance e•, aluatiutu involves a determination that is not without leg -al implications. Tu this end, pnor to making an adverse employment decision based on the foregoing standard, the authority with jurisdiction might wish to consult with counsel. D-1.1 Individuals with Handicaps or Disabilities- The Reha- bilitation .act of 1973, as amended, 29 U.S.C. 791 et seq., and implementing regulations, prohibit discrimination against those with handicaps or disabilities under any program receiv- ing financial assistance from the federal ,government. The Americans with Disabilities .act of 191Yn, 42 L.S.C. § lN'lol, et srq.. also prohibits employment discrimination by certain pn- vate emplovers against individuals with disabilities. In addition, many states have enacted legisladon prohibiting ,iiscriminadon .[gains[ those with handicaps or disabilities. These laws prevent the exclusion, denial of benefits, refusal to hire or promote, or other discriminatory conduct against an individual based on a handicap or disability, where the individual involved can, with or without reasonable accommodation, perform the essential functions of the job without creating undue hardship on the employer or program involved. Application of this standard should be undertaken with these issues in mind. The medical requirements of the 1997 edition of this stan- dard were initially developed and found to be job -related by a subcommittee comprised of medical doctors, physiological specialists, and fire service professionals, as processed through the NFPA consensus standards -making system. Changes for the current edition have been proposed by a task group com- prised of similar expertise. The standard provides, to the extent feasible, that decisions concerning candidates and cur- rent members with medical ailments, handicaps, ordisabilities be made after case-bv-case medical evaluations. Thus, most medical conditions have been assigned to Category B. The medical requirements in this edition of the standard were revised based on the essential functions contained in Appendix C- It is recognized that some fire -fighting functions and tasks can vary from location to location due to differences in department size, functional and organizational differences, geography, level of urbanization, equipment utilized, and other factors. Therefore, it is the responsibility of each individ- ual fire department to document, through job analysis, that the essential functions performed in the local jurisdiction are substantially similar to those contained in Appendix C. There are a wide variety ofjob apalytic techniques available to document the essential functions of the job of a member. However, at a minimum, any method utilized should be cur- rent, in writing, and meet the provisions of the .'americans with Disabilities Act (29 (:h7R 1630.2(n) (3) j. Job descriptions should focus on critical and important work behaviors and specific tasks and functions. The frequency and/orduraaion of task per- formance, and the consequences of failure to perform the task should be specified The working conditions and environmen- tal hazards in which the work is performed should be described. The job description should be made available to the fire service physician for use during the preplacement medical examination for the individual determination of the medical suitability of applicants for member. D-1.2 :%nd-Discrimination Laws. Finally, users of this stan- dard should be aware that. while courts are likely to give con- siderable weight to the existence of a nationally recognized standard such as NFPA 1582, .Standard on ,Medical Reptirrmenu for Firr Fighters and Information for Fire, Department Phyvinaru Mader v. Sioux Gateurav Fir. Departmeni, 497 N.W'2d 838 ( 1993)1, reliance on the standard alone could be insufficient to withstand a challenge under the anti -discrimination laws. Even in the case of Category A medical conditions, courts can still require additional expert evidence concerning an individ- ual candidate's or member's inability to perform the essential functions of thejob. Until the courts provide furtherguidance in this developing area of law, some uncertainty as to the degree and nature of the evidence required to establish com- pliance with the anti -discrimination laws will remain. D-1.3 Individuals Who .are Members of Protected Classes (Race, Sex, Color, Religion, or National Origin). Title DTI of the Civil Rights .act of 1964. as amended, 42 U.S.C. 2000e, and implementing regulations by the Equal Employment Opporni- nity Commission (EEOC) prohibit discrimination in employ- ment on the basis of race, sex, color, religion, or national origin (i.e., protected classes). Under Tide VII, an "employer" is defined, generally, to mean a person with "15 or more employ- 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) Several federal jurisdictions have held that unpaid volunteers are not considered to be "employees" under Title DTI. ;additionally, many states, cities, and localities have adopted similar legislation. Generally, physical performance or other requirements that result in "adverse impact' on mem- bers of a protected class (e.g., on the basis of gender) are required to be validated through a study in accordance with EEOC guidelines, if such requirements are to be relied on in making employment decisions. Under EEOC guidelines, a study validating employment standards in one jurisdiction can be transportable to another jurisdiction (and therefore used in lieu of conducting a separate study). However, specific pre- conditions must be met in this regard, and the authority hav- ing jurisdiction should seek the advice of counsel before relying on a transported validation study. D-1.4 Pregnancy and Reproductive. Federal regulations, as well as many court decisions, including the U.S. Supreme Couri s decision in International Union, et al. a fohnson Controls, Inc. (499 U.S. 187, 111 S.Cc 1 196 (1991) J, have interpreted the requirements of Title VTI with respect to pregnancy and reproduction. The authority having jurisdiction should seek the advice of counsel in resolving specific questions concern- ing these requirements as well as other requirements that can be imposed by state or local laws. D-2 Choosing a Fire Department Physician. Several factors should be considered in chasing a fire department physician. There are relatively few physicians with formal residency train- ing and certification in occupational medicine. The fire depart- ment physician needs to be qualified to provide professional expertise in the areas of occupational safety and health as these areas relate to emergency services. For the purpose ofconduct- ing medical evaluations, the fire department physician needs to understand the physiological and psychological demands placed on members and needs to understand the environmen- tal condiuons under which members have to perform. 158'2-27 Therefore, physicians with specialties other than occupa- uonal need to be considered, as well as the physician's back- ground and experience. Knowledge of occupational medicine and experience with occupational heath programs, obviously, would be helpful. The physician has to be committed to meeting the require- ments of the program, including appropriate record keeping. His or her willingness to work with the department to contin- ually improve the program is also important. Finally. his or her concern and interest in the program and in the individuals in the department is vital. There are many options for obtaining, phvsician services (a) Physicians could be paid on a service basis or through a contractual arrangement. (b) For volunteer departments, local physicians could be willing, to volunteer their services for the program, with addi- tional member arrangements for pavment of laboratory test- ing, x-rays, and so forth. (c) Some departments could utilize a local health care facility for medical care. However, in that case, the department should be sure to have one individual physician responsible for the program, record keeping, and so forth. (d) 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 member's own health insurance. For example, the health insurance provider could allow the member to have a yearly physical, normally performed by the member's personal physician. The health care insurance provider could allow that physical to be per- formed by the fire department physician with some degree of reimbursement. D-3 Coordinating the Medical Evaluation Program. An indi- vidual from within the department should be assigned the responsibility for managing the health and fitness program, including the coordination and scheduling of evaluations and examinations. This person should also act as liaison between the department and the physician to make sure that each has the information necessary for decisions about placement, scheduling appointments, and so forth. Confidentiality of all medical data is critical to the success of the program. Members need to feel assured that the infor- mation provided to the physician will not be inappropriately shared. No fire department supervisor or manager should have access to medical records without the express written consent of the member. There are occasions, however, 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 for decision making. In that situation, written medical consent should be obtained from the individual 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 essential elements are not lost With addi- tional funding, other programs or testing can be added to enhance the program. D-i Table D4 represents a comparison between NFPA 1582 and OSHA 29 CFR 19 W.134. 2000 Ediwn 1582-28 %IEDtt:.\L RFQUIRENIEN"TS FOR FIRE FRAITERS AND INFOPMATION FOR FIRE DEP:\RT\[ENT PM!3V_G\_N5 Table D-4 Comparison of OSHA 29 CFR, Parts 1910.134, -Medical Requirements" and NFPA 1582. Standard on Medical Requirements fur Fire Fighters and Information for Fire Department Physicians, 2000 Edition NFPA 1582 OSHA 1910.134 2-1 Medical Evaluation Process. IThe employer must establish and implement those elements of the written respiratory pro- 24A ` The fire department shall establish and implement a medical evalua- , tecuon program necessary to ensure that any tion process for candidates and current members. employee using a respirator voluntarily is med- ically, 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 wntten respiratory protecon pro - ;,cram those employees whose only use of respi- rators involves the voluntary use of filtering face pieces (dust masks). I 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 shottld also act as with the complexity of the program to admin- liaison between the department and the physician to make sure that each has the information necessary for decisions about placement, scheduling ister or oversee the respiratory protection pro - gram and conduct the required evaluations of appointments, and so forth. the program effectiveness. Confidentialiry 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- i ager should 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-dury medical evalu- medical evaluation to determine the ations. employee's ability to use a respirator, before the employee is fit tested 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. (Shtet 1 of 5) 2000 Ed,Gon \PPENOIX D Table D4 Comparison of OSHA 29 CFX Parts 1910.134, ":Medical Requirements" and N FPA 1582, Standard on .Hedical Requirements for Fire fighters and Information for Fire Department Physicians, 2000 Edition (Continued) MFPA 1582 OSHA 1910.134 2-1.3 The fire department shall ensure that the medical evaluation process j (3) Follow-up medical examination. and all medical evaluations meet all of the requirements of Section 2-1. (i) The employer shall ensure that a follow-up medical examination is prodded for an employee who gives a positive response to any question among questions 1 through 8 in Sec- uon '2. Part A of Appendix C or whose initial medical examination demonstrates the need for follow -tip medical examinations. 2-1.4 Each candidate or current fire fighter shall cooperate, participate, and comply with the medical evaluation process and shall provide complete and accurate information to the fire department physician. 2-1.5• Each candidate or current fire fighter shall, on a timely basis, report to the fire department physician any exposure or medical condition that could interfere with the ability of the individual to perform as a fire Fighter. 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- sonnel as authorized by the fire department physician. When other quali- fied personnel are used, the fire department physician shall review the data gathered during the evaluation. 1582-29 (ii) The follow-up medical examination shall include anv medical tests, consultations, or diagnostic procedures that the physician or licensed health care professional (PLHCP) deems necessary to make a Final determina- tion. (7) Additional medical evaluations. At a mini- mum, the employer shall provide additional medical evaluations that comply with the requirements of this section if- (i) An employee reports medical signs or symptoms that are related to ability to use a respirator; (ii) A PLHCP, supervisor, or the respirator pro- gram administrator informs the employer chat an employee needs to be re-evaluated; (iii) Information from the respiratory protec- tion program, including observations made during tit testing and program evaluation, indicates a need for employee reevaluation; or (iv) A change occurs 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. (Shut 2 of S) 2000 Edition 1582-30 3IEDIGAL. REQUIRENIE`tTS FOR FIRE FIGHTERS AND INFORNULTION FOR FIRE DEPNRTMENT PM7;1Cj,,NS Table D4 Comparison of OSHA 29 CFR, Parts 1910.13.4, "Medical Requirements" and NFPA 1582, Standard on Wedical Requirements for Firs Fighters and Information for Fire Department Physicumt, 2000 Edition (Conhnurd) NFPA 1582 2-2 Fire Department Roles. 2.2.1 The fire department shall have an officially designated physician who shall be responsible for guiding, directing, and advising the members with regard to their health, fitness, and suitability for duty as required by NFPA 1500, Standard an Firr Department Occupational Safety and Health PrvyTram. 2-2.2 The fire department physician shall be a licensed doctor of medicine or osteopathy. D-2 Choosing a Fire Department Physician. Several factors should be consid ered in choosing a fire department physician. There are relatively few physi cians 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 lions, 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 Forvolunteer 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. 2000 Edition OSHA 1910.134 (2) Medical evaluation procedures. (i) The employer shall identify a physician or other licensed health care professional (PLHCP) to perform medical questionnaire or an initial medical examination that obtains the same information as the medical question- naire. (ii) The medical evaluation shall obtain the information requested by the questionnaire in Sections 1 and Part A of Appendix C of this section. (Sheet 3 of 5) I APPENDIX D 1582-31 Table D4 Comparison of OSHA 29 CFR, Parts 1910.134, "Medical Requirements" and NFPA 1582, Standard onMedical Requirements for Fire Fighters and Information for Fire Department Physicians, 2000 Edition (Continued) NFPA 1582 2-2.3" For the purpose of conducting medical evaluations, the fire depart- ment physician shall understand the physiological and psychological demands placed on members and shall understand the environmental con- ditions under which members must perform. The fire department shall pro- vide the fire department physician with a current job description for all fire department positions and ranks. B-1 Occupational Safety and Health Problems for Fire Fighters. Fire Fighting and emergency response are very difficult jobs. People in these jobs per- form functions that are physically and psychologically very demanding. These functions are often performed under very difficult conditions. (See .-appendix C.) Studies have shown that fire -fighting functions require work- ing at near maximal heart rates for prolonged periods of rime. Heavy pro- tective equipment (including respirators) and the heat from the fire contribute to this physical load. Fire fighters and emergency response personnel also are exposed to many toxic substances during their work. Carbon monoxide is the most common contaminant; studies have shown indiNidual exposures as high as 5000 ppm in actual tires. Other significant exposures common in fires include cya- nide, acrolein, hydrogen chloride, nitrogen dioxide, and benzene. The burning of plastics and other synthetic materials can expose fire fighters to other toxic materials such as isocyanates and nitrosamines. Hazardous mate rials incidents can involve exposures to many other toxic materials. While the use of respirators helps to reduce exposures, mechanical, environmen- tal, and behavioral factors can limit their use during all phases of a fire. OSHA 1910.134 (e) Medical evaluation. Using a respirator may place a physiolo cal burden on employees that varies with the type of respirator worn, the job and the workplace conditions in which the respirator is used. and the medical status of the employee. Accordingly, this paragraph specifies the minimum requirements for medi- cal evaluation that emFloyers must implement to determine the employee's ability to use a respirator. (5) Supplemental information for the PLHCP (i) The followin-a information must be pro- vided to the PLHCP before the PLHCP makes a recommendation concerning an employee's ability to use a respirator: (A) The type and weight of the respirator to be used by the employee; (8) The duration and frequency of respirator use (including use for rescue and escape); (C) The expected physical work effort; (D) Additional protective clothing and equip- ment to be worn; and (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- ments directly to the PLHCP or having the documents transferred from the former PLHCP to the new PLHCP. However, OSHA does not expect emplgyers to have employees medically re-evaluated solely because a new PLHCP has been selected. (Sher a of 5) 2000 Editmn 1582-32 MEDiGIL REQUIREMENTS FOR FIRE FICHTERS,\ND tNFORStATION FOR FIRE DEPARTMENT PI ItiSICL4uS Table D-k Comparison of OSHA 29 CFR, Parts 1910.134, ":Medical Requirements" and NFPA 1582, Standard on Medicai Requirements for Fin Fighters and Information for Fire Department Physicians, 2000 Edition (Continued) NFPA 1582 OSHA 1910.134 2-4.1 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 training or emergency operational environment as a membrr..3Lnv applica- ble OSHA standards, such as 29 CFR 1910.120, "Hazardous Waste Opera- (t) Obtain a written recommendation regard- ing the empPlovee's ability to use the respirator tions and Emergency Response," 29 CFR 1910.134, "Res iratory Protection," p 29 CFR 1910.95, "Occupational Noise Exposure," and 29 CFR 1910.1030, from the PLHCP. The recommendation shall provide only the following information: -Bloodborne 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 Elie respirator.; (B) The need, if any, for follow-up medical evaluations; and (C) A statement that the PLHCP has provided Elie 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 employee's 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 P R (4) Administration of the medical question- naire and examinations. (i) The medical questionnaire and examina- tions shall be administered confidentially dur- ing the employee's normal working hours or at a ume 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 opportuniry to discuss the question- naire and the examination results with the PLHCP. (Shirt 5 of 3) 2000 Edition APPENDIX F Appendix E Sample Forms This appendix is not a part of the requirements of this ,VFPA doc- ument but is included for informational purposes only. E-1 Physical Exam Sununary. The fire department physician can report results of the periodic medical evaluation, which is designed to evaluate a member's continued ability to perform his or her duties and to detect any significant changes in the condition of his or her health, on a form like the Physical Exam Summary. (.Ste Figure E-1.) E-2 Medical Examination Report The fire department physi- cian can record information from the medical examination on a form like the Medical Examination Report. (SeeFigure&2.) 1582-33 Appendix F Referenced Publications F-1 The following documents or portions thereof are refer- enced within this standard for informational purposes only and are thus not considered part of the requirements of this standard unless also listed in Chapter 6. The edition indicated here for each reference is the current edition as of the date of the NFPA issuance of this standard. F-l.l NFPA Publications. National Fire Protection Associa- tion, 1 Batterymarch Park, P.O. Box 9101. Quincy, tifA 02269- 9101. NFPA 1001, Standard for Fire Fighter Professional Qualiftra. tioru, 1997 edition. F-1.2 ANSI Publications..3unerican National Standards Insti- tute, Inc., 11 West 42nd Street, 13th floor, New York. NY 10036. ANSI S3.1. Maximum Permissible,Ambient ,Voise Levels for.Audi. ometric Test Room, 1991 edition. ANSI S3.6, Speciftcation for,{udiometers. 1996 edition. 2000 Edition EMPLOYMENT PHYSICAL SERVICES ATTACHMENT i58'Z-34 JIEDICII, REQUIREMENTS FOR F1RE FIGHTERS AND INFORNUT(ON FOR FIRE DEPARTMENT PMSICL NS FIGURE E-1 Form for fire department physician's report. Physical Exam Summary Employer: Employee's Name: Position Title: Date of Exam: Examining Physician: Components Performed Within Normal Limits Abnormal, Able to Perform Job Tasks Abnormal, Unable to Perform Job Tasks Significant Changes Noted from Previous Exam (if applicable) ❑ Physical exam ❑ Audiogram ❑ Pulmonary function ❑ Treadmill stress ❑ EKG- 12lead ❑ Chest x-ray Cl 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 NFPA "sic&# Exam Summary (1 at 2) 2000 Edition APPENDIX F 1582-35 RGL'RE E-1 (Continue(L) Hof P.l.: MriNts. is a v o. Fire Fighter Police Officer with the department. The purpose of this annual physical is to establish fitness for the continuation of those duties. He/she has enjoyed good health. Mr./Mrs. voiced the following questions: Medical History Surgical History Medications D.M. — Orthopedic — HTY — ENT — CVD — Optho Asthma _ Other Allergies Social History ROS Smoke GI — PPD _ Hematochezia Quit _ Stool caliber -- — -. — --- -------------- ---Pkyc-- -- --------- —_ 8awe1-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 EKG/TMT Blood _ Near _ RR H/H _ Far _ Target WBC _ Corrected — Intetp Glu Stool OB — Stage achieved Cho[ — Positive Puirn HDL — Negative FVC Ratlip o Pred UA Un Blood FEVI SGO SGOT� — Protein �o Pred SGPT _ _ Glucose GGT Other NFPA P okal Exam Summary (2 of 2) 20M EdM" 1582-36 MEDICAL REQUIREMEYTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEP.kRTNIENT PH SICLLNS FIGURE E-2 Medical examination report form. Medical Examination 1. NAME (Last) (First) (Middle) 2. SEX 3. DATE OF EXA`IINATION 4. PLANT OR DIVISION 5. SOC. SEC. OR 6. OCCUPATION 7. DATE LAST EXANMINATION EMPLOYEE NO. 8. REASON FOR PRESENT EXAMINATION ❑ PRE -PLACEMENT ❑ D.O.T. ❑ SURVEILLANCE rl r'vliv MMATTON n arT 9. TEMP. 10. PULSE It. BLOOD PRESSURE l2. HEIGHT FT IN. 13. WEIGHT 1 14. TITMUS SNELLING 15. VISION UNCORRECTED CORRECTED 16. COLOR VISION (Use Code)* DISTANT RE 20/ BOTH LE 20/ RE 20/ BOTH LE 20/ 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. Heart 27, Abdomen 28. Inguinal, e.g., hernia 29. Genitalia ' Code: 0 — within normal limits t — Significantly abnormal X — Not examined NFPA ModkAg E""nedon form (1 of 12) 1 2000 Edibon APPENDIX F FIGURE E-2 (Cmrtu�) 1582-37 30. Pelvis 31. Anus and rectum -------------------------------- Prostate Proctoscopic -----� ------- t 32. Spine 33. Skin 34. Arms -------------------------------- Hands ------------------- 35. Legs --------------------------------- Feet -------------------- _ 36. Peripheral -Vascular 37. Neurologic 38. Emotional status 39. Other 40. Urine dip: Glucose: Albumin: S.G.: Heme: Leukocyte -Esterase: Other. 41. Flex k 42. Step test R 43. Body fat 1 r4 Ifs 44. PFT 45. Audio 46. Chest x-ray (use 0, 1, or X) 47. EKG (use 0, 1, or X) and specify test used 48- Hemocult Nl� 49. Back eval. 50. Tetanus 51. PPD 52. Stress test • Code: 0 — Within normal limits 1 —Significantly abnormal X — Not examined NFPA Medical Examination Form (2 of 12) 2000 Edition 1582-33 MEDICAL REQUIREWENTS FOR FIRE FIGKiERS AND INFORNIATION FOR FIRE DEPARTMENT FHYSICLMNS FIGURE E-2 (Continued) 53. Other x-ray or laboratory findings 54. Physician's summary, remarks, and diagnoses, including -recommendations made to patient (include code numbers for diagnoses and conditions found) 55. Recommendations/Restrictions 59. Work qualification: 56. R.N. signature 57. Physician's signature 58. Patient's signature 60. Contact person: 161. Date: ' Code: 0 — Within normal limits I —Significantly abnormal X — Not examined 2000 Eoltfon 62. Initial: NFPA IMdloN ExoMmadon Forth (2 of 12) I Ar?END(X F FIGURE E-2 (Continued) 1582-39 Health History Yes No If "Yes," Give Details. Have You Had Any Surgeries/Operations: On your back arm. leg. or knee? To treat a hernia? Varicose veins? Other operations? Have you ever been hospitalized? Allergy — Have You Ever Had or Do You Currently Have: Serious allergy? Bad reaction to any medication? Advised not to take any medication (e.g.. aspirin)? El 11 Skin — Have You Ever Had or Do You Currently Have- Hives/eczema or rash? Chronic skin problems (e.g.. cuts slow to heal)? Excessive skin dryness? Problems with "easy bruising Chemical or jewelry rash/sensitivity? Neuro — Have You Ever Had or Do You Currently Have: A psychiatric or emotional problem? Numbness/weakness/paralysis? Dizziness or fainting spells? SevcmJfrequent or migraine headaches? Head injury, concussion, or skull fracture? Neurological disorders? Seizures or blackouts? F1 ❑ Stroke? F1 ❑ Eyes/Ears — Have You Ever Had or Do You Currently Have: Hearing loss? Frequent ear infections? NFPA Medical EiamIrted" Form (I or I! I 2000 Edrfon 1582-40 MEDICAL REQUIREMENTS FOR F(RE FIGHTERS AND INFOR.N0 NON FOR FIRE DEPARTSIENT PI--11COCN5 FIGURE E-2 (Continued) Health History Yes No If "Yes," Give Details. Ringing in ears? El E-1 Other ear problems? Glaucoma or cataracts? Red eyes? Eye injury/vision loss? Other eye problems (e.g., strain from VDT use)? Glasses/contacts? Date of last vision screen? a o Head/Neck — Have You Ever Had or Do You Currently Have: Date of last dental exam: El R Recent problems with teeth/dentures? 1-1 EJ Frequent mouth ulcers/infections? Sinus or hay fever? EJ Frequent sore throats? 1-1 Frequent nose bleeds? 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? 11 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? 0 El Morc than three episodes of bronchitis in El EJ one year? Ever smoked tobacco in any form? EJ EJ How long: Yrs. Packs per day: When quit: Had a chest x ray? Last time: NFPA Modksl FiAn tnsUan Form (! of 12) 2000 Editfon R APPENDIX F FIGURE E-2 (Continued) l 58'_-4 I Health History Yes No If "Yes," Give Details. Heart — Have You Ever Had or Do You Currently Have: Rheumatic fever or heart murmur? ❑ ❑ Heart disease? ❑ ❑ Treated for heart condition? ❑ ❑ Unusually cold or bluish -colored hands ❑ ❑ or feet? High blood pressure. If "Yes," how is it ❑ ❑ 0 Medicine 0 Diet 0 Exercise treated? Do you have a history of elevated cholesterol? ❑ ❑ Anemia or any blood disease? ❑ ❑ Phlebitis, varicose veins, or blood clots/ ❑ ❑- poor circulation? Chest pain with activity? ❑ ❑ GI — Have You Ever Had or Do You Currently Have: Ulcers? ❑ ❑ Hiatal hernia? ❑ ❑ Indigestion, pain, or unusual burning in stomach? ❑ ❑ Vomiting of blood? ❑ ❑ Bloody/tarry bowel movements? ❑ ❑ Colitis or nervous stomach? ❑ ❑ Yellow jaundice or hepatitis? ❑ ❑ 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? D D Hernia? ❑ ❑ Blood in urine? ❑ ❑ NFVA Modleal ExaTlnatlon For. (6 of 12) 20M Editwn I582-42 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFORMATION FOR FIRE DEPART"dENT PHYSICIANS FIGURE Erg (Con6nued) 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 Do You Currently Have: Arthritis, rheumatism, neck, back, or spine injury or disease? ❑ ❑ Been treated for a back problem? ❑ ❑ Recurrent stiffness or back pain? ❑ ❑ Bursitis, tendonitis? ❑ ❑ Recurrent pulled muscles or sprains? ❑ ❑ _ Hand or wrist injury or problem? ❑ ❑ Hip or knee injury or problem? ❑ ❑ Ankle or foot injury or problem? ❑ ❑ Frostbite? ❑ ❑ Job requiring heavy lifting or standing, or sitting for long periods of time? ❑ ❑ 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? ❑ ❑ Do you practice monthly breast self -exam? ❑ ❑ Have you ever had a mammogram? ❑ ❑ 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? ❑ ❑ Do you practice monthly testicular self -exam? ❑ NFCA Al"cat Eiuminown Forth I7 o1 in 2000 Edition APPENDIX F 1582-43 FIGURE E•2 (Continued.) Health History General Lifestyle I. (Check the answer that bent describes you.) General health O Poor O Fair O Good O Excellent c7o Seatbelt use 0 0-24% O 25-49175 O 50-74% O 75-100% Daily stress O Low O Moderate O High Average hours sleep O 6 hours or less O 7-8 hours O 8 hours or more Average meals daily O 1 meal 0 2 meals 0 3 or more -Number of eggs per week O 0-1 O 2 O 3 or more Average number red meat meals per week O 0-1 O 2-3 O 3 or more Average number of alcoholic beverages/beers O 0-5 O 6-14 O 15 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? ❑ ❑ Year immunized: Do you take any prescription medication? ❑ ❑ Do you take nonprescription medication (or drug) on a regular basis? ❑ ❑ over-the-counter General Lifestyle 11. Do you participate in a workplace wellness/ ❑ ❑ help promotion program? Which of the following would you like to see offered and would you participate in? Cholesterol screen ❑ ❑ Blood pressure screen ❑ ❑ Weight loss ❑ ❑ Nutrition program ❑ ❑ Stress management ❑ ❑ Smoking cessation ❑ ❑ CPR ❑ ❑ NFVA Afadlcat examtnedw form M of 12) 20M Edition 1582-14 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS .'ND INFOR,AMON FOR FIRE DEPARTMENT PH4S(CL1NS FIGURE &2 (Continued_) Health History Yes No If "Yes," Give Details. 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 a job 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.)? Been hospitalized in the last five years? ❑ ❑ Have you had any illness or injury that we have not asked you about? ❑ ❑ Work History It: Do you have hobbies, such as furniture refin- ishing, painting, hunting, shooting, or model building? ❑ ❑ Do you moonlight or have a second job? ❑ ❑ Work History Ill. Exposures — Have You Ever Worked Around the Following: Chemical plant? ❑ ❑ Coke oven? ❑ ❑ Construction? ❑ ❑ Cotton, flax, or hemp mill? ❑ ❑ Electronics plant? ❑ ❑ Farm? ❑ ❑ Foundry? ❑ ❑ NFPA M*Oe l Exwninsdoo Form (9 of 12) 2000 Editbn ,k"ENDIX F FIGURE E-2 (Continued.) 1582—(5 Health History Yes No If "Yes," Give Details. Hazardous waste industry? ❑ ❑ Hospital? ❑ ❑ Lumber mill" ❑ ❑ Metal production'? ❑ ❑ Mine? ❑ ❑ Nuclear industry? ❑ ❑ Paper mill? ❑ ❑ Pharmaceutical? ❑ ❑ Plastic production? ❑ ❑ Pottery mill? ❑ ❑ 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? ❑ ❑ Benzidine? ❑ ❑ Beryllium? ❑ ❑ BIS chlormethyl ether? ❑ ❑ Cadmium? ❑ ❑ Carbon disulfide? ❑ ❑ Carbon tetrachloride? ❑ ❑ Chlorine? ❑ ❑ ' Chlorodane? ❑ ❑ Chloroform? ❑ ❑ NFP►, ki"cal Examina0on Form (10 of 12) 2000 Edtlon 1582-46 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS A.'ND INFORMATION FOR FIRE DEPARTSIENT PMSICLVNS FIGURE E8 (Contimied.) Health History Yes No It "Yes," Give Details. Chloroprene? ❑ ❑ Chromates? ❑ ❑ Chromic acid mist? ❑ ❑ Cutting oils? ❑ ❑ DDT? ❑ ❑ Dieldrin? ❑ ❑ Dibxin? ❑ ❑ Dust, coal? ❑ ❑ Dust, sandblasting? ❑ ❑ Dust, other? ❑ ❑ _. Ethyl dibromide? ❑ ❑ Ethylene oxide? ❑ ❑ Extreme heat or cold? ❑ ❑ Heptachlor? ❑ ❑ Hexachlorobenzene? ❑ ❑ Isocyanates (TDI, MD1)? ❑ ❑ Loud or continuous noise? ❑ ❑ Mercury? ❑ ❑ Methylene chloride? ❑ ❑ Microwaves, lasers? ❑ ❑ Nickel? ❑ ❑ PCBs? ❑ ❑ Pesticides, herbicides? ❑ ❑ Phenois? ❑ ❑ Phosgene? ❑ ❑ Plastics? ❑ ❑ Radioactive materials? ❑ ❑ Roofing materials? ❑ ❑ Rubber? ❑ ❑ Silica? ❑ ❑ NFPA Medicd EnminsUan form (11 of 12) 2000 Edition APPENDIX F FIGURE E•2 (Continued.) 1582--47 Health History Yes No If "Yes," Give Detalls. Solventsidegreasets? ❑ ❑ Soots and tars? ❑ ❑ Spray painting? ❑ ❑ TRUPER chloroethylene? ❑ ❑ Vinyl chloride? ❑ ❑ List any toxin slchemicals/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 a job applicant. Date: Signature: Examiner: NFPA ModeW axaiMmtlon Feml (12 of 14 2000 Edtlon 1582-48 MEDICAL REQUIREMENTS FOR FIRE FIGHTERS AND INFOR.NATION FOR FIRE DEPARTMEN-l' PH551CL1NS Index (02000 National Fire Protection ,Association. All 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 are 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- Abdominal organs ................................. 3-9, A-3.9.2 Administrators, guide for fire department ................ App. D Advanced life support (ALS) ................ 5-2.2, A-5-1.1, A-5-2.2 Antidiscrimination laws ................................. D-1.2 Approved (definition)............................14.1, A-l-l.1 Asthma............................................... 8-3.2 Audiometry ........................................ 8-2.3.2.4 Authority having jurisdiction (definition) .............14.2, A-14.2 -B. Basic life support (BLS)...........................5-2.2. A-5-2.2 Blood and blood -forming organs ....................3.15, A-5-15 Blood exposures ........................ ......... 4-2.1. A-4-2. l Bloodborne pathogen exposures, post -exposure prophylaxis for ............................. A4-2.1 Body fluid exposures.............................4-2.1. A4-2. l Burn injury ......................................... A-5-3.2 -C- Cancerrisk........................................... B-1.4 Candidates Definition .................................... 14.3.A-14.3 Medical evaluation ............... 2-1. 2-3, A-2-L 1, A-2-1.5. A-2-3 Category A medical condition ............. sa Medical conditions Category B medical condition ............. see Medical conditions Chemicals ..................................... 3-20, A-3-20.2 Chest wall.........................................3-7. A-3-7 Confidentiality, medical evaluations ......................... 26 .D. Dental..........................................1 5. A-3-5.2 Diabetes mellitus ....................................... B-3. I Disabled persons ....................................... I)-I.I Down member.. . . . . .................................A-5-3.2 Drugs ......................................... 3-20. A 3-20.2 Definition .......................................... 14.6 -E- Ears............................................34.A-0-4.2 Electrocardiography ............................ 8-2.2. 8-2.3.2.5 Emergency medical services (EMS) .............. 5 2.2. 5-3, A-5-1.1 A 5-2.2, A-5-3.2 Definition ......................................... 14.18 Endocrine disorders...............................3-16, A-346 Epilepsy.............................................. B-3.6 Esophagus.........................................3 6,A-3-6 Essential job functions (structural fire -fighting) ........... App. C Definition .......................................... 14.7 Evaluations .................. see Functional capacity evaluation; Medical evaluations Exposure incidents..................................4.2, A4-2 Definition .......................................... 14.9 Extremities .................................... 3-12, A-3-12.2 Eyes.................................. ........... 3-3.A-3-3 2000 Edition •F- Fire department Guide for administrators ............................. App. D Members .................................... ser Members Fire department physician ..... 2.2. A-2-2; see alto Medical evaluations Choosing ................................ 2-2.2. A-2-2.2, D.2 Definition..........................................14.10 Immunizations. responsibility for ......................... 44 Incident scene treatment, role in ......... 5-3.2. A$L 1 to A-5-L2 A-5-3.2 Infection disease control, role in ................. 4-1.2, A-1-2.1 Information for ... ................................. App. B Record keeping and reports of ........................... 26 Functional capacity evaluation ...... ...................... 8-2.6 Definition..........................................14.11 -G.- Gastrointestinal systems............................3-9, A-3-9.2 Genitourinary systems...................3-10. A-340. B-3.4. D-1.4 -H- Head.........................................3.2.1. A-3.2. l.2 Health and fitness coordinator ............................ 2-2.4 Definition..........................................14.12 Health and safety officer ................................. 2-2.4 Definition..........................................14.13 Hearing ....................... 34, A-34.2, B-1.4. 8-2.3.2.4. 8-3.5 Heart ..... 3-8.1. A-36.1, B-1.2. 8-1.4. B-2.1 to 8-2.2, 8-2.3.2.5. B-3.3 Hepatitis B immunizations ...................... ........ .A-" Immunisations ..................................... 4.4.A-" Implementation of standard .........................l-3. A-1-3.2 Incident commander ........................ 5-1.2. 5-2.1. A-5-4.4 Incident safety officer...................................5-2.1 Incident scene rehabilitation and medical treatment ....Chap. 5. A-5 Infection control officer.................................4.1.2 Definition..........................................14.14 Infection control program (infectious and communicable disease control) ..........................Chap. 4. A4 Definition..........................................14.15 .L- Laboratory testa.....................................B-2.3.2.1 Larynx........................................... U.A-3-6 Legal considerations ..................................... D-1 Lungs .... . ..........................3-7. A-3-7, B-2.3.2.3, B-3.2 -M- Malignant diseases...............................3-18. A-3.18.2 Medical conditions Category A ............. Chap. 3. A-3; set alto specific body part+ and conditions Definition .........................................14.4 INDEX Category B. . ...... .. .......Chap 3. A-3: see also specific body parts and conditions Definition ........................................ 1-4.5 Specific............................................. B-3 Medical evaluations Content of .......................................... &2.3 Coordination of program ............................... D-3 Definition .._........ Guidance for ............... ......................... &2 Incident scene .............. ................... 5-3, A-5-3.2 OSHA 1910.134 compared ........................ Table D-4 Periodic .............................. 2-1.2, 24, A 2-4, &2.2 Preplacement and base line .............. 2-1.2. 2-3. A-2.3, &2.1 Process ................................. 2-1, A-2-1.1, A-2-1.5 Records, results, reporting, and confidentiality .........2-6. &2.4 Sample forms, medical examinations ................ App. E Return -to -duty .............. 2-1.2, 2.5, A-2-5.1. A-2-5.3 to A-2-5A Tactical level management component (TI_MC) ........... 5-4.5 5-4.7, A-5-4.5 Medical examinations ................ see also Medical evaluations Components of .................................... &2.3.2 Definition ......................................... 1-4.17 Sample forms ..................................... App. E Medical history ...................................... &2.3.1 Medical process ................................ . . Chap. 2, A-2 Medical services, emergency ..................... see Emergency medical services (EMS) Medically certified Definition.........................................14.19 Periodic medical evaluation .........................24, A•24 Preplacement medical evaluation ....................2-3, A-2.3 Reports ......................................2.6.2 to 2.6.3 Retum-todury medical evaluation ......... 2-5.2 to 2-5.3, A-2-5.3 Medications .................................... 3-20, A-&20.2 Members Current Definition......................................1-4.20.1 Medical evaluations ............2.1, 24. A-2-I.I, A-2-1.5, A-2-4 Definition..................................14.20. A-1-4.20 Down............................................ A-5.3.2 " Incident scene rehabilitation and medical treaanent ....................... Chap. 5. A-5 Infection control program ....................... Chap. 4. A4 Occupational safety and health problems .......... H-1, Table D-4 Metabolic disorders ................... ............ 3-16. A-5-I6 Musculoskeletal system ................ . .......... A-5-3.2, B-2.6 •N- Neck......................................... 3.2.2. A-3-2.2.2 Neurological disorders ......................... .... 3-13.A-&13 Nose... ". A.." -O- Occupational history ................................. &2.3.1 Occupational Safety and Health Admmiatration (OSHA) I910.134 comparison ............... Table D4 Occupational safety and health problems ... ........ .&1. Table D4 Oropharynx...................................... _ M. A-3-6 1582-49 .P. Personnel accountability system ................ . ..........5. 4.8 Physical load, of fire -righting functions .................... B-1.2 Physician ........................ see Fire department physician Post -exposure.. ................. . A-4-2.1 to A-4-2.2 Pregnancy ............................... ....... &3.4. D-1.4 Protected classes ......................... .. ......... D-1.3 Psychiatric conditions ........................ .. 3-19, A-3-19.2 Pulmonary function testing, ................... .... &2.3.2.3 Purpose of standard ......................... .... 1-2. A-1.2.2 -R- Reactive airways disease ...................... ......... &3.2 Referenced publications .................... Chap. 6, B-4. App. F Reports and records Exposure incidents ................... 4-2. 4-3.2. A-4-2, A-4-3.2 Immunization records ................................ A-4-4 Medical evaluations .......................... ......... 2-6 Sample forms, medical examinations ....................App. E Reproductive system ............... 3-10.1. A-3-10.1.2, &3.4. D-1.4 Respiratory disease risk .................... &1.4. B-2.3.2.3. B-3.2 Ribs .......................................... 3-11.A-&11.2 Risk, increased ........................................ &1.4 Sacroiliac joints ................................ 3.11. A 3-11.2 Sample forms ........................................ App. E Scapulae ...................................... 3-II,A1.11.2 Scope of standard.......................................1-1 Second opinions ....................................... &2.5 Seizures .............................................. &3.6 Shall (definition)......................................14.21 Should (definition)....................................1-4.22 Skin .......................................... 3-14.A-3-14.2 Smoke inhalation ..................................... A-5-3.2 Spine ......................................... 3-I1.A-3-11.2 Standard (definition)...................................14.23 Styesstesting.......................................... 3.2.2 Systemic diseases ............................... 316, A-3-17.2 -T Tactical level management component (TU(C) ............... 5-4 A-5-4.3 to A-54.5 Definition..........................................14.24 Toxic substances ............................ &1.3, &1.4, B-3.4 Trachea ............. .............................. 3d.A-3d Triage, incident scene ............................. 5.3, A-5-5.2 Tuberculosis ................ ....................... 4-3.A-4-3 Tumors ......................................... 3.18, A-3-18.2 -U- Urinary system .............................. 3-I0.2, A-3-10.2.2 -V Vascular system. . . . ..................... &8.2. A-M. &1.4. &3.3 Vision............................................ 3-3. A-3-3 -X- X rays ........................... . ........... 13,2.2, &2.3.2.2 Cot,iw 2000 Edition