Occupation Agency Code Work Location Work Supervisor Duty tel. #
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1 PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal or regulatory investigations or prosecutions. The Social Security Number, authorized by Public Law Section 7 (b) and Executive Order 9397, is used as a unique identifier to distinguish between employees with the same names and birth dates and to ensure that each individual's record in the system is complete and accurate and the information is properly attributed. Employee info: Occupation Agency Code Work Location Work Supervisor Duty tel. # Visit for: PERIODIC POLICE/SECURITY WORKER 714 CERTIFICATION EXAMINATION Medical History 1. Is your work exposure history current (OPNAV 5100/15), and is surveillance/ppe consistent with exposures/occupations 2. Has anything about your health status changed since your last examination 3. Have any medications changed since your last exam 4. Have you ever had a major illness or injury 5. Have you ever had a hospitalization or surgery 6. Have you ever had cancer 7. Have you ever had a back injury 8. Do you drink 6 or more drinks per week (beer, wine, liquor) 9. Have you ever smoked 10. Do you currently smoke or use smokeless tobacco or electronic cigarettes ( packs/day) 11. Heart disease, high blood pressure, stroke or circulation problems 12. Current medication use (prescription or over the counter) 13. Medication allergies 14. Any reproductive health concerns 15. Shortness of breath 16. Headache, dizziness, light headedness, weakness 17. Change or loss of vision in either eye 18. Problems with night vision 19. Change or loss in hearing 20. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem 21. Repeated episodes of loss of or near loss of consciousness 22. Epilepsy or seizures 23. Problems with balance or coordination 24. Numbness, tingling, or weakness in hands or feet 25. Thyroid disease (including heat or cold intolerance) 26. Diabetes (sugar disease) or other endocrine disorder (thyroid, parathyroid, pituitary, adrenal gland) 27. Mental or emotional illness 28. Sleep disorder, breathing pauses while sleeping, sleep apnea, loud snoring, insomnia, daytime sleepiness 29. Depression, difficulty concentrating, excessive anxiety 30. Personality or behavior change 31. Exposure to potentially infectious body fluids Page 1 of 5 Do not re-use this form after 5/20/2019
2 Medical History (continued) Comments on Medical History: Page 2 of 5 Do not re-use this form after 5/20/2019
3 Studies and Immunizations Urine: Urine Ph Urine specific gravity Urine urobilinogen Urine protein Urine glucose Urine ketones Urine blood Urine nitrite Urine RBCs Urine WBCs Immunizations: Hepatitis B vaccine #1 Hepatitis B vaccine #2 Hepatitis B vaccine #3 Hepatitis B titer Td (Tdap once) Other studies or comments: Other studies or comments: Audiogram (DD 2215/2216) Vision With Correction Without Correction DISTANCE NEAR Right Left Both Right Left Both 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / Visual fields Horizontal (lateral) field of vision, degrees Right Left Color vision Pass Fail Ishihara - # of plates HRR (Hardy Rand Ritter) City University Farnsworth D15 Other Comments on Studies, Immunizations, and Vision: Page 3 of 5 Do not re-use this form after 5/20/2019
4 Vital Signs Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight: Physical Examination Overall physical fitness Metabolic disturbance (fever, tachycardia) Eyes Gaze (muscle balance, nystagmus) Ears (tympanic membranes) Nose Throat Thyroid Cardiovascular system Respiratory system Back & musculoskeletal system Skin (malignant & pre malignant conditions) Central nervous system Peripheral nervous system (strength, sensation, DTRs) Psychiatric (especially emotional stability) WNL Other (describe) Comments on Physical Exam findings: Page 4 of 5 Do not re-use this form after 5/20/2019
5 Assessment Blood & body fluid precautions knowledge adequate Certification Examinations Qualified Not Qualified Pending POLICE/SECURITY WORKER (714) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM for Return for follow-up exams: POLICE/SECURITY WORKER. Other disposition: Discussed results of exam with employee Limitations and comments: Provider Signature & Stamp: Date: Page 5 of 5 Do not re-use this form after 5/20/2019
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
Occupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
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