Fillable Medical Exam Form 2018 Massachusetts 0 2 (1) 1 (Commonwealth of Massachusetts)

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Medical Exam Form 2018 Massachusetts 0 2 (1) 1 (Commonwealth of Massachusetts)

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Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 1
Initial-Hire Medical Standards Medical Examination Form
Commonwealth of Massachusetts Human Resources Division
Thi
s form is to be used for all medical examinations performed pursuant to the Medical and Physical Fitness Standards Regulations
for Public Safety Personnel. Communities not subject to these regulations may also use this examination form.
Completed by Municipality (type or print in ink)
Name of Examinee (Last, First, Middle)
Municipality: Social Security # Date of Birth
Appointing Authority Email: Dept. Chief Email:
Position: ☐Police Officer ☐Firefighter
Exam: ☐Initial Exam ☐ Other Exam (Please explain)
Priv
acy Notice
The collection of the information on this form is authorized under regulations filed with the Secretary of State of the
Commonwealth of Massachusetts. This information will be used to determine the fitness-for-duty of public safety personnel.
The information may be disclosed to the Municipal Keeper of the Records; an appropriate government agency for law
enforcement purposes; where relevant in a legal or administrative proceeding to which the Commonwealth or a
Commonwealth municipality is a party or has interest; to a government agency upon its request when relevant to its decision
concerning employment or other benefits; to an expert consultant or other person under contract with the Commonwealth of
Massachusetts to fulfill an official agency function including audits of services provided under these Medical Standards; to
an investigator, administrative judge, or complaints examiner appointed for the investigation of a formal complaint of
employment discrimination; to officials with responsibility for administering workers’ compensation, disability retirement,
and other benefit entitlements; to an examinee’s private treating physician; and to medical personnel retained by the
Commonwealth of Massachusetts to provide medical services in connection with an employee’s health or physical condition
related to employment. Completion of this form is voluntary. If this information is not completed, the examination may be
considered incomplete. Knowingly providing false or incomplete answers may result in the rescission of a conditional job
offer or dismissal if discovered at a later time.
Consent and Certification (Completed by Examinee)
I hereby
authorize collection and use of the information on this form for the purposes stated in the above Privacy Notice. I
have read and understand the provisions of the Privacy Notice included in this form. I certify that all the information given by
me in connection with this examination will be correct and complete to the best of my knowledge and belief.
I also understand that if I fail an initial medical examination, I may undergo a reexamination within 16 weeks of the date of
the failure of the initial examination. If I fail to pass the reexamination, my appointment can be rescinded. (M.G.L. Chapter
31, Section 61A.)
Signature of Examinee Date
It is mandatory that a signed copy of this cover page, and a copy of the Medical Verification Section (page 8) be returned by
e-mail to PAT@mass.gov.
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signature
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Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 2
Name of Examinee Social Security Number
A.
Medical History (completed by examinee before examination)
INSTRUCTIONS: Please answer all questions accurately and completely. If you do not understand any question, you
should request clarification from the examining physician. The information provided regarding your medical history and
health habits will be used to make a medical assessment of whether you can safely and effectively perform the essential
functions of a public safety position. Detailed medical information will be treated confidentially. It is essential that you
answer all questions accurately and completely. Please note that a history of a health problem will be carefully evaluated
and will not necessarily disqualify you from employment.
Do you now have or have you ever had any of the following: (Check Yes or No)
Yes
No
Yes
No
1. Fracture of skull, jaw or facial bones
40. Stroke, Aneurysm, or Bleeding in head
2. Concussion or other injury to head
41. Multiple sclerosis or muscular dystrophy
3. Thoracic outlet syndrome
42. Myesthenia gravis or ALS
4. Fracture of neck, vertebrae or spine
43. Epilepsy or seizures
5. Recurrent back or neck pain
44. Dementia or memory loss
6. Degenerated or herniated disc
45. Migraines or other severe headaches
7. Back injury or other abnormality
46. Paralysis or muscle weakness
8. Back, spine or neck surgery
47. Other neurological disorders
9. Osteoporosis
48. Eczema or other skin disease
10. Arthritis or joint injury or disease
49. Skin grafts
11. Amputation involving hand or foot
50. Bleeding disorder/anticoagulation
12. Carpal tunnel syndrome
51. Sickle cell disease or trait
13. Other hand or wrist problems
52. Blood clots or thrombosis
14. Dislocation of any joint
53. High or low blood cell counts
15. Injury or abnormality of arms or legs
54. Enlarged or ruptured spleen
16. Need for corrective lenses
55. Diabetes or high blood sugar
17. Deficiency of color vision
56. Thyroid or other endocrine disorder
18. Disease of the eyes or sinuses
57. Cancer, malignancy or tumor
19. Loss of hearing
58. Mental or emotional disorder
20. Exposure to loud noise
59. Mental health treatment of any type
21. Disease of the ear or vertigo
60. Lupus, scleroderma, dermatomyositis
22. Deformity of mouth or jaw
61. Heat stroke, frostbite or burns
23. Speech impediment or disorder
62. AIDS, HIV infection or hepatitis
24. Tuberculosis
63. Any history of alcohol or drug abuse
25. Pneumothorax or collapsed lung
64. Current use of any prescribed drug
26. Bronchitis, asthma or other lung
disease
65. Allergies or chemical sensitivities
27. Abnormal electrocardiogram (EKG)
66. Occupational (work) injuries
28. Heart disease or cardiac abnormality
67. Disability or compensation claim
29. Irregular heart rhythm
68. Asbestos or toxic chemical exposures
30. Angina/chest pain/shortness of breath
69. Required light or restricted duty
31. Hypertension/high blood pressure
70. Military rejection or medical discharge
32. Organ transplant
71. Medical treatment in past 12 months
Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 3
33. Liver, pancreas or gall bladder
disease
72. CAT Scan, MRI or other special tests
34. Ulcer or bowel disease
73. Smoked cigarettes or tobacco products
35. Intestinal bleeding
74. Are you pregnant?
36. Hernia of any type
75. Any sleep disorder
37. Kidney or bladder disease
76. Heavy snoring
38. Abnormal balance or coordination
77. Shortness of breath with light activities
39. Fainting, blackouts or dizzy spells
78. Other health conditions
Pl
ease explain “yes” answers by referencing item number.
Provide (in the section to the right of each #) pertinent information relative to diagnosis and treatment for each
“yes” response. Include dates for injuries, illnesses and follow up treatments. Please use the back of this page if necessary.
#
#
#
#
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Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 4
Name of Examinee Social Security Number
B.
Medical Examination
INSTRUCTIONS: After reviewing the Medical History provided in Section E, conduct a comprehensive examination of
all systems necessary to determine the examinee’s fitness under the applicable public safety position Medical Standards.
The examination should include, but not be limited to, the areas listed below. If the examiner finds that the examinee has
physical examination findings relevant to a determination of whether the examinee will likely be able to safely and
effectively perform the essential functions of the position being considered, the examiner is responsible for documenting all
such conditions.
Height Weight Blood Pressure / Temperature
Pulse
Vision Testing Without Corrective Lenses With Corrective Lenses
Distant
Rt. 20/ Lt. 20/ Both 20/ Rt. 20/ Lt. 20/ Both 20/
Near Rt. 20/ Lt. 20/ Both 20/ Rt. 20/ Lt. 20/ Both 20/
Visu
al Fields (degrees)
Right: Temporal Nasal
Left: Temporal Nasal
Color Vision:
☐
Passed
☐
Failed
EXAMINATION Normal Abnormal (Identify by number and explain if abnormal)
1.
Skin
2.
Head, face and scalp
3.
Ears, tympanic membranes
4.
Eyes, pupils, fundi, motion
5.
Nose, sinuses, olfaction
6.
Mouth, throat, speech
7.
Neck, thyroid
8.
Heart
9.
Varicosities, bruits, pulses
10.
Chest, lungs
11.
Breasts (if indicated)
12.
Abdomen, hernia
13.
Rectum (if indicated)
14.
Endocrine
15.
Spinal mobility, alignment
Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 5
16.
Upper extremities, hands
17.
Lower extremities, feet
18.
Muscle strength, tone
19.
Gait, Rhomberg
20.
Balance, coordination
21.
Reflexes
22.
Cranial Nerves
23.
Mental Status
24.
General Appearance
☐
MD
☐
DO
☐
NP
☐
PAC (Check one)
Print name of examining health care provider __
Signa
ture of examining health care provider _______________________________________ Date _________________
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signature
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Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 6
Name of Examinee Social Security Number
C.
Laboratory and Diagnostic Tests
INSTRUCTIONS: Three diagnostic tests are required under the Medical Standards. Although not specifically required
under the Medical Standards, additional tests may be performed. Some tests may be required by the appointing authority
or approved by the appointing authority to further evaluate conditions detected on the medical history form and/or during
the physical examination. For each test performed indicate below whether the results were normal or abnormal and
document any abnormal results in Section H. Copies of all laboratory reports should be attached to this form as part of
the permanent record.
REQUIRED TESTS:
A.
Spirometry* ☐ Normal ☐ Abnormal
B.
Audiogram* ☐ Passed ☐ Failed
C.
Purified Protein Derivative (PPD) Test or interferon-gamma release assay (IGRA) for tuberculosis
6
☐ Negat
ive ☐ Positive
OTHER TESTS:
D.
D. Urine Dipstick* ☐ Normal ☐ Abnormal Sp. Gravity Protein Sugar
E.
E. CBC* ☐ Normal ☐ Abnormal
F.
F. Chemistry panel* ☐ Normal ☐ Abnormal
G.
Urine drug screen* ☐ Negative ☐ Positive
H.
Electrocardiogram* ☐ Normal ☐ Abnormal
I.
Chest X-Ray* ☐ Normal ☐ Abnormal
J.
Hepatitis B Immunization* Dates of Immunizations: #1 #2 #3
K.
Tetanus Immunization* Dates of Immunizations:
L.
Other*
6
Applicants with newly found positive tuberculosis test results must be evaluated in consultation with a
tuberculosis specialist regarding need for treatment and any restriction on participation in activities involving
close contact with others.
*The candidate should be informed of abnormal results in these evaluations in writing so he/she may consult with
his/her primary care physician.
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.
Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 8
Name of Physician
Address of Physician Telephone:
Date of Medical Examination: for Fire Department
☐
Police Department
☐
Physician Email:
PHYSICIAN'S CERTIFICATION OF FITNESS
I have reviewed the medical examination for the following examinee using the Human Resources Division's Medical
Standards Program for Public Safety Personnel:
☐ Initial Exam
☐ Other Exam (Please explain)
Name of Examinee: Social Security #:
Home Address:
Home Telephone:
Physician must certify whether candidate passed or failed the medical exam:
☐
I hereby certify that the above named examinee passed the medical examination.
Or
☐
I hereby certify that the above named examinee failed the medical examination.
Section Failed
☐
Category B
☐
Section Failed
Category B ☐
Section Failed
☐
Category B
☐
Section Failed
Category B ☐
Section Failed
Category B ☐
Section Failed
Category B ☐
PHYSICIAN’S NOTICE OF EXAMINEE’S FAILURE TO PROVIDE COMPLETE & ACCURATE MEDICAL HISTORY
(See Privacy Notice on Page 1 of this form and please provide comments below and attach documents if necessary.)
☐
MD
☐
DO
☐
NP
☐
PAC (Check one)
Print name of examining health care provider __
Signature of examining health care provider _______________________________________ Date _________________
The Medical Verification Section must be returned to the Appointing Authority. The Appointing Authority will
forward the Medical Verification Section, along with a signed copy of page one of this Medical Examination Form
to the Human Resources Division (HRD). These Sections may be e-mailed to PAT@mass.gov
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Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 9
F.
Category B Medical Alert Form
INSTRUCTIONS: The purpose of this form is to ensure that a passing examinee with one or more Category B conditions
which do not result in a failure, but do represent a potential future risk to the examinee in terms of his/her future health and
ability to safely perform the duties of a police officer/fire fighter based on the existing medical understanding of the
progression of the condition, is notified of the condition(s) and the recommendation to monitor the condition(s) on a
regular basis. In addition, given the inherent risk to the individual and others while serving in a public safety position, the
same information will be provided to the appointing authority. It is the responsibility of the examining physician to
determine when it is appropriate to use this form, to ensure that the form is completed properly, and to inform the examinee
in person and the appointing authority by phone or mail. [NOTE: Upon request, the examinee can be provided with a
copy of this form.]
Completed by the Physician
LISTING OF CATEGORY B CONDITION(S) (such as diabetes, disease of the eye, etc.) THAT REPRESENT A
POTENTIAL RISK TO THE EXAMINEE: Be specific regarding each condition and the current status as of the
examination date listed above.
Commonwealth of Massachusetts Initial Hire Medical Standards 2018 Page 10
Completed by the Examinee Immediately after Presentation by the Examining Physician
ACKNOWLEDGEMENT OF RECEIPT OF SUPPLEMENTAL MEDICAL INFORMATION:
The examining physician presented and explained the medical condition(s) listed above. By signing this form, I
acknowledge that:
I asked questions of the examining physician to ensure I understood the medical condition(s) at least at a basic
level that would enable me to discuss the issues with my personal physician.
I understand that the condition(s) does not disqualify me from being hired as a police officer/fire fighter.
I understand that it is the recommendation of the examining physician that I discuss the condition(s) with my
personal physician and develop an ongoing plan for monitoring my condition since it is likely to progress at
some point in the future and it is impossible to predict how quickly or slowly that change may take place.
I understand that given the inherent risks to myself, other members of the department, and the public while
performing the duties associated with a police officer/fire fighter, the same information will be shared with the
appointing authority.
I acknowledge and give my permission for the physician to release my personal medical information specific to
the condition(s) listed above ONLY to the appointing authority.
My Name (Printed): Today’s Date:
My Signature:
Completed by the Physician
PERFORMANCE OF RESPONSIBILITIES:
I acknowledge informing the examinee of the potential risks listed above on the date listed on this form.
I also informed the appointing authority of the existing conditions for this individual and recommendation for ongoing
monitoring of the individual through: (check one)
☐ a formal letter (attached) ☐ an e-mail (printed and attached)
Signature of Physician:
Date of Examination:
Name of Examinee (Printed):
Name of Physician (Printed):
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Medical Exam Form 2018 Massachusetts 0 2 (1) 1 (Commonwealth of Massachusetts)

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Completed 19 July 2020

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