Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 7
D.
Additional Notes
INSTRUCTIONS: Use this section to summarize any additional medical history information, abnormal physical
examination findings, abnormal diagnostic or laboratory test results, and any other relevant information obtained during
your evaluation. Please note that sufficient information must be documented so that your decision-making process is clear
to any reviewer in the event that the examinee appeals an adverse fitness determination.
In the event that an examinee does not pass the examination, please document in the Medical Verification Section whether
each disqualifying condition represents a Category A or Category B condition, as defined in the Medical Standards. If
Category B, please explain below why you determined that the examinee’s condition precluded his or her safe and effective
performance of one or more of the essential functions of the public safety position. Additional pages (i.e. transcription
notes) may be attached to this form. Also, note in section F(Category B medical alert form) of this form any medical
conditions that, though not immediately disqualifying, may either need to be assessed through functional performance or
that have a medically reasonable chance of progression to a point where they may adversely affect safe and effective
performance of the relevant essential job functions.
MD
DO
NP
PAC (Check one)
Print name of examining health care provider __
Signature of examining health care provider _______________________________________ Date _________________
E.
Medical Verification Section
INSTRUCTIONS: Review the medical history, physical examination documentation, diagnostic test results, and
laboratory reports in relation to the applicable public safety position Medical Standards and make a determination
(regarding) whether the examinee meets all requirements of the Medical Standards. Conditions classified under Category A
in the Medical Standards preclude an examinee from work in the public safety position. Conditions listed under Category B
in the Medical Standards require careful individual consideration and may require further evaluation to determine whether
the condition would preclude this individual from safely and effectively performing the essential functions of the public
safety position. If there is uncertainty regarding an examinee’s health status or functional abilities which could be resolved
with additional information, the examinee should be offered the opportunity to provide medical records, reports from
medical specialists, or any other relevant information in order to determine passed or failed status. In this case, the
examinee should be advised by the examining physician as to what information is needed for follow up. He or she should
be provided with a reasonable, but specific amount of time during which to provide the reports to the examining physician,
who will thereafter advise the municipality of the status of the examinee.
If an examinee fails an initial medical examination, he or she is eligible to undergo a reexamination within 16 weeks of the
date of the failure of the initial examination. If the examinee opts for a reexamination, he or she must arrange it with the
municipal authority.
NOTE: In cases where the medical examination has been performed by a nurse practitioner or physician's assistant,
a doctor of medicine or osteopathy must sign this Medical Verification Section.
When all necessary information has been received and reviewed, complete this Medical Verification Section and distribute
per instructions below. Medical examination records are the property of the municipal authority. They must be kept
accessible for the duration of the examining physician’s contract for use in the event of an audit, appeal or disability
proceeding. If the contract terminates or expires, the physician will be instructed to transfer these records to his or her
successor. The physician, however, may retain copies of his or her own examination reports and selected materials.
