Respirator clearances, OSHA surveillance opinions, federal pre-placement exams, overseas medical clearances and wildland fire medical templates, with who signs each.
Much occupational health paperwork comes from OSHA standards. Before a worker wears a respirator, a physician or other licensed health care professional (PLHCP) reviews the OSHA Respirator Medical Evaluation Questionnaire (Appendix C to 29 CFR 1910.134) and gives the employer a written recommendation. Similar written opinions follow evaluations for bloodborne pathogens, HAZWOPER, silica, lead and beryllium. Federal positions with medical standards use the OPM Certificate of Medical Examination (OF 178), and overseas postings use State Department forms DS-1843 and DS-1622.
The employer pays for OSHA-required evaluations and receives a written opinion, not the full findings. Most OSHA opinions have no official form, so you write a short letter limited to what the standard allows and leave unrelated findings out. For wildland firefighters, the Forest Service uses condition-specific templates: the employee completes Part A, the treating provider completes Part B, and Forest Service Medical Officers decide. Spanish versions exist for 2 forms, including the Appendix C questionnaire.
States whether the employee is medically able to use the respirator, any limitations, and whether follow-up evaluation is needed, as required by 29 CFR 1910.134(e)(6).
Appendix C to 29 CFR 1910.134Apéndice C: Cuestionario de Evaluación Médico obligado por la OSHA
Mandatory medical questionnaire (or equivalent exam) used by a PLHCP to determine whether an employee is medically able to wear a respirator before fit testing and use.
Limited written opinion on whether hepatitis B vaccination is indicated, or that the employee was informed of post-exposure evaluation results and follow-up needs, under 29 CFR 1910.1030(f)(5).
Attending physician's opinion on whether the employee has conditions increasing risk from hazardous waste work, emergency response or respirator use, with recommended work limitations, under 29 CFR 1910.120(f)(7).
PLHCP's opinion to the employer after a respirable crystalline silica surveillance exam: respirator limitations, specialist referral and exposure limits (with employee authorization), and next exam date.
Pre-placement or periodic medical examination of applicants/employees in federal positions with medical standards or physical requirements, documenting findings that would limit performance of the essential job functions (5 CFR 339).
ILO classification of a chest radiograph for pneumoconiosis outside the CWHSP (e.g. asbestos/silica medical surveillance, clinical or legal reads).
Referral physician evaluates, within 5 days, whether a medical condition precluded a DOT-tested employee from providing a sufficient urine or oral-fluid specimen and recommends a determination to the MRO.
Opinion to the employer within 45 days of a beryllium surveillance exam: exam date, that it met the standard, PPE/respirator limitations, and (with authorization) exposure limits, CBD diagnostic center referral or medical removal.
Examining physician's opinion on conditions increasing risk from lead exposure, recommended protective measures/exposure limits, respirator limits and blood lead results, which drives medical removal protection decisions.
Treating provider documents diagnosis, prognosis, treatment and functional status for asthma, reactive airway disease, COPD or sleep apnea so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for seizures, syncope, stroke, headache or other central nervous system conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for diabetes mellitus or pre-diabetes so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for gastrointestinal conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Catch-all provider statement on a condition not covered by a specific template, with mitigations supporting a medical waiver for wildland fire duties.
Treating provider documents diagnosis, prognosis, treatment and functional status for genitourinary conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for hearing loss or hearing aid use so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for heart disease, murmurs, heart surgery or cardiac implantable devices so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for blood (hematopoietic) disorders so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for hypertension, aneurysm or vascular disease so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for immune system or allergic disorders so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for musculoskeletal or peripheral/central nervous system conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for use of a prosthesis so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Prescriber lists a wildland firefighter's medications and states whether side effects could impair safe performance of fire duties, for Medical Officer review.
Treating provider documents diagnosis, prognosis, treatment and functional status for psychiatric conditions and medications so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for thyroid or other endocrine conditions so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Treating provider documents diagnosis, prognosis, treatment and functional status for vision deficits so Forest Service Medical Officers can decide medical qualification or a waiver for a wildland firefighter position.
Appendix B-I to 29 CFR 1910.1043Standardized respiratory questionnaire used in cotton dust medical surveillance (with spirometry) to detect byssinosis.
Appendix D to 29 CFR 1910.1001Standardized respiratory disease questionnaire required at pre-placement (Part 1) and periodic (Part 2) asbestos medical surveillance exams.
CDC/NIOSH 2.8B Reader's ILO classification of a coal miner's surveillance chest radiograph for pneumoconiosis under the Federal Mine Safety and Health Act.
Pediatric history and physical exam used by State Department MED to medically clear a child family member for an overseas post.
Full history and physical exam used by State Department MED to grant an overseas medical clearance to Foreign Service and other U.S. government employees, applicants and eligible family members.
Provider describes an employee's condition, functional limitations and recommended workplace accommodation (and its duration) so the State Department can decide a reasonable-accommodation request.
Provider's opinion, after a full clearance exam, on whether an individual can live and work in the austere conditions of an ESCAPE (high-threat) post.
Physician's annual certification that a mine rescue team member is physically fit for prolonged mine rescue and recovery work under strenuous conditions (30 CFR 49.7 / 49.17).
Certifies that a reactor operator license applicant or licensed operator meets the medical requirements (ANSI/ANS-3.4 or 15.4) and requests any license conditions recommended by the examining physician.
Physical examination and Licensed Physician's Certificate for a driver education instructor applicant.
Medical provider's written recommendation after cholinesterase testing of a pesticide handler (removal from exposure or return to work).
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OSHA has no form for it. Under 29 CFR 1910.134(e)(6), the recommendation states whether the employee is medically able to use the respirator, any limitations on its use, whether follow-up evaluation is needed, and that the employee received a copy. Its content is limited to those points. The employer pays for the evaluation, and the PLHCP gives the employee a copy of the recommendation.
No. The employee completes Part A of the Appendix C questionnaire and sends it confidentially to the PLHCP, who reviews it and may add Part B questions. A 'yes' to any of questions 1 to 8 in Section 2 calls for a follow-up exam. The employer gets only the written recommendation. OSHA publishes the questionnaire as a web page in English and Spanish, with no official PDF.
The examining physician, physician assistant or nurse practitioner completes Part C, pages 4 to 6, of the Certificate of Medical Examination. The agency attaches the job's functional requirements as Part B. The finished form goes back intact to the employing agency in its 'Confidential - Medical' envelope, and the agency medical officer completes Part D. The agency pays for or reimburses required exams.
Yes. The examinee's own physician or health care provider completes the DS-1843 for an overseas medical clearance. The examinee fills pages 1 to 3, and the examiner completes Sections VIII to XIII and signs on page 5. Lab results must be attached, plus an ECG tracing from age 50. The form is scanned and sent electronically to State Department MED, not by mail. Children 11 and younger use the DS-1622.