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PrePlacement-NonCounty Welcome to Los Angeles County, Department of Health Services

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EMPLOYEE HEALTH SERVICES
NON-COUNTY
HEALTH CLEARANCE INSTRUCTIONS
REV 06/2014
A8
Welcome to Los Angeles County, Department of Health Services (DHS). You are required to obtain a
health clearance by Employee Health Services (EHS) prior to beginning your work assignment. You
must successfully complete the Human Resources in-processing and criminal background check prior
to beginning the EHS health clearance process. This packet includes health screening forms and
questionnaires that should be completed by you and your physician or a licensed health care
professional (PLHCP) prior to your visit to EHS for your health clearance. Only return the E2
certificate and appropriate forms if indicated to EHS on the day of your appointment/visit.
This packet contains the following forms/questionnaires:
E2 – Pre-Placement Tuberculosis History and Evidence of Immunity -This form contains
the pre-placement health screening requirements needed to work at a DHS facility. Tuberculosis
screening and evidence of immunity to vaccine-preventable diseases are mandatory.
K-NC – This form is a declination to receiving any non-mandatory vaccines
N-NC – This form is used for a N95 respirator fit test to be completed by your PLHCP. If your
job assignment requires a N95 respirator, you must be fit tested for the N95 respirator. If your
job assignment involves Airborne Infection Isolation Rooms (AIIR), you will need to be fit tested.
If your job assignment does not involve AIIR, you will not need to complete this form or the
questionnaire below (Form P-NC).
o P-NC – This form is an Aerosol Transmissible Disease Respirator Medical Evaluation
Questionnaire. You must complete this questionnaire and submit to your PLHCP prior
to the respirator fit test.
**NOTE**: N95 respirator is the most commonly used respirator in DHS facility,
however, if you need a respirator greater than a N95 (such as full-face respirator), you
must complete the Respirator Medical Evaluation Questionnaire (Form O-NC) and
submit to your PLHCP prior to fit test. Form O-NC is available on EHS link at
www.dhs.lacounty.gov .
Once you have been cleared by EHS, you may report to Human Resources to obtain an ID badge and
begin your work assignment. If you have any questions, please contact the facility EHS.
Sincerely,
EMPLOYEE HEALTH SERVICES
EMPLOYEE HEALTH SERVICES
PRE-PLACEMENT TUBERCULOSIS HISTORY
AND EVIDENCE OF IMMUNITY
See GENERAL INSTRUCTIONS on last page.
FOR NON-DHS/NON-COUNTY WFM
FIRST, MIDDLE NAME:
BIRTHDATE:
E or C#:
HOME/CELL PHONE #:
DHS FACILITY:
DEPT/WORK AREA/UNIT:
JOB CLASSIFICATION:
NAME OF SCHOOL/EMPLOYER/AGENCY/SELF:
AGENCY CONTACT PERSON:
AGENCY PHONE #:
CONTINUE ON NEXT PAGE
E2
In accordance with Los Angeles County, Department of Health Services policy 705.001, Title 22, and CDC
guidelines all contactors/students/volunteers working at the health facilities must be screened for communicable
diseases prior to assignment. This form must be signed by a healthcare provider attesting all information is true
and accurate OR workforce member may supply all required source documents to DHS Employee Health
Services.
A
TUBERCULIN SKIN TEST RECORD
0.1 ml of 5 tuberculin units (TU) purified protein derivative (PPD) antigen intradermal
STATUS
Indicate:
Reactor
Non-Reactor
Converter
DATED
PLACED
STEP
MANUFACTURER
LOT #
EXP
SITE
*ADM BY
(INITIALS)
DATE
READ
*READ BY
(INITIALS)
RESULT
1
st
mm
2
nd
mm
If either result is positive, send for CXR and complete Section C below.
OR
B
Negative IGRA
(<12 months)
Date:
Results
LA County
Outside Document
STATUS
If CXR is positive for TB, DO NOT CLEAR for hire/assignment.
Refer Workforce Member for immediate medical care.
C
Positive TST
Date:
Results mm
LA County
Outside Document
STATUS
CXR (<12 months)
Date:
Results
LA County
Outside Document
OR
D
Positive IGRA
Date:
Results
LA County
Outside Document
STATUS
CXR (<12 months)
Date:
Results
LA County
Outside Document
OR
E
History of Active TB with
Treatment
Date:
months with
Outside Document
STATUS
CXR (<12 months)
Date:
Results
Outside Document
OR
CONFIDENTIAL
PRE-PLACEMENT TUBERCULOSIS HISTORY AND EVIDENCE OF IMMUNITY
PAGE 2 OF 4
LAST NAME
FIRST, MIDDLE NAME
BIRTHDATE
E or C#
CONTINUE ON NEXT PAGE
E2
F
History of LTBI Treatment
Date:
months with
Outside Document
STATUS
CXR (<12 months)
Date:
Results
Outside Document
AND
G
IMMUNIZATION DOCUMENTATION HISTORY (THESE VACCINATIONS ARE MANDATORY)
Date
Received
Titer
If not immune, give
Vaccination x 2,
unless Rubella x 1
Date
Received
Vaccine
Declined Vaccination
(may be restricted from
hospital/patient care)
Measles
Immune
Non-Immune
Equivocal
Laboratory
confirm of disease
OR
X 2
OR
Decline only for true
medical contraindication,
must include medical
documentation
Mumps
Immune
Non-Immune
Equivocal
Laboratory
confirm of disease
OR
X 2
OR
Decline only for true
medical contraindication,
must include medical
documentation
Rubella
Immune
Non-Immune
Equivocal
Laboratory
confirm of disease
OR
X 1
OR
Decline only for true
medical contraindication,
must include medical
documentation
Varicella
Immune
Non-Immune
Equivocal
Laboratory
confirm of disease
OR
X 2
OR
Decline only for true
medical contraindication,
must include medical
documentation
AND
H
Vaccination
Date Received
Date of Declination Signed
Tetanus-diphtheria (Td) every 10 years
OR
Acellular Pertussis (Tdap) X 1
AND
I
Vaccination (MANDATORY to offer to
WFM who have potential to be exposed
to blood or body fluid)
If not reactive,
vaccinate with HepB
series (3 doses)
Date
Vaccine
N/A (job duty does
not involve blood or body
fluid)
Hepatitis B
Surface Ab
Titer
(HbsAb)
anti-HBs
Date
Titer
AND
OR
Date
Declination signed
Reactive
Non-reactive
Date
HbcAb/ Non-reactive
anti-HBc Reactive
Date
HbsAg Non-reactive
Reactive
AND
CONFIDENTIAL
PRE-PLACEMENT TUBERCULOSIS HISTORY AND EVIDENCE OF IMMUNITY
PAGE 3 OF 4
LAST NAME
FIRST, MIDDLE NAME
BIRTHDATE
E or C#
CONTINUE ON NEXT PAGE
E2
J
Vaccination
Date Received
Location
Received
OR
Date Declination Signed
Seasonal Influenza (one
dose for current season)
Note: Must wear mask during influenza season.
AND
K
Respiratory Fit Test (Complete Form N-NC)
Date:
Pass Fail PAPR
N/A (Job duty does not involve airborne precautions)
L
Color Vision (MANDATORY for WFM
working with point of care testing.)
Date:
Pass Fail
N/A (Job duty does not involve point of care testing)
FOR HEALTHCARE PROVIDER:
I attest that all dates and immunizations listed above are correct and accurate.
Date:
Physician or Licensed Healthcare Professional Signature:
Print Name:
Facility Name/Address:
Phone #:
OR
FOR WORKFORCE MEMBER:
Required source documents attached.
Workforce Member Signature:
Date:
DHS-EHS STAFF ONLY
WFM completed pre-placement health evaluation.
Date of clearance:
Signature:
Print Name:
Today’s Date:
SECTION
GENERAL INSTRUCTIONS FOR EACH SECTION
TUBERCULOSIS DOCUMENTATION HISTORY
ALL WORKFORCE MEMBER (WFM) SHALL BE SCREENED FOR TB UPON HIRE/ASSIGNMENT
A
WFM shall receive a baseline TB screening using two-step Tuberculin Skin Test (TST).
Step 1: Administer TST test, with reading in seven days.
Step 2: After Step 1 reading is negative, administer TST test, with reading within 48-72 hours. If both readings are negative, WFM is
cleared to work. WFM shall receive either TST or IGRA and symptom screening annually.
a. Documentation of negative TST within 12 months prior to placement will be accepted. WFM shall receive a one-step TST with
reading within 48-72 hours. If result is negative, WFM is cleared to work;
b. Documentation of negative two-step TST within 12 months prior to placement will be accepted. WFM is cleared to work.
If TST is positive, record results and continue to Section C.
B
WFM shall receive a baseline TB screening using a single blood assay for M. tuberculosis (IGRA). If negative result, WFM is cleared
to work. WFM shall receive either TST or IGRA and symptom screening annually.
a. Documentation of negative IGRA within 12 months will be accepted. WFM is cleared to work.
If IGRA is positive, record results and continue to Section D.
CONFIDENTIAL
PRE-PLACEMENT TUBERCULOSIS HISTORY AND EVIDENCE OF IMMUNITY
PAGE 4 OF 4
LAST NAME
FIRST, MIDDLE NAME
BIRTHDATE
E or C#
Rev 06/2014
E2
SECTION
GENERAL INSTRUCTIONS FOR EACH SECTION
TST POSITIVE RESULTS
If CHEST X-RAY IS POSITIVE, DO NOT CLEAR FOR HIRE/ASSIGNMENT, AND
REFER WORKFORCE MEMBER FOR IMMEDIATE MEDICAL CARE
C
If TST is positive during testing in Section A or C above, send for a chest x-ray (CXR). If CXR is negative, WFM is cleared to work.
Documentation of negative CXR within 12 months prior to placement will be accepted for clearance to work. WFM shall be symptom
screened for TB annually.
D
If IGRA is positive during testing in Section D above, send for a CXR. If CXR is negative, WMF is cleared to work. Documentation of
negative CXR within 12 months prior to placement will be accepted for clearance to work. WFM shall be symptom screened for TB
annually.
E
If WFM have a documented history of active TB, send for a chest x-ray (CXR). If CXR is negative, WFM is cleared to work.
Documentation of negative CXR within 12 months prior to placement will be accepted for clearance to work. If documentation is
supported, WFM is cleared to work. WFM shall be symptom screened for TB annually. Record documentation result in this section.
F
If WFM have a documented history of latent tuberculosis infection (LTBI) treatment, send for a chest x-ray (CXR). If CXR is negative,
WFM is cleared to work. Documentation of negative CXR within 12 months prior to placement will be accepted for clearance to work.
If documentation is supported, WFM is cleared to work. WFM shall be symptom screened for TB annually. Record documentation
result in this section.
IMMUNIZATION DOCUMENTATION HISTORY
Documentation of immunization or adequate titers will be accepted. If WFM is not immune against communicable diseases as listed in this section,
WFM shall be immunized (unless medically contraindicated). WFM who declines the vaccination(s) must sign the mandatory declination form. WFM
who declines the vaccination(s) may be restricted from patient care areas of the hospital or facility. If WFM is non-immune or decides at a later date
to accept the vaccination, DHS or WFM contract agency will make the vaccination available.
G
Documentation of laboratory evidence of immunity or laboratory confirmation of disease will be accepted OR documentation of two
doses (live measles, mumps and varicella) and one dose of live rubella virus vaccine. Measles vaccine shall be administered no
earlier than one month (minimum 28 days) after the first dose. Mumps second dose vaccine varies depending on state or local
requirements. Varicella doses shall be at least 4 week between doses for WFM. If Equivocal, WFM needs either vaccination or re-
draw with positive titer. DHS-EHS must be notified if WFM does not demonstrate evidence of immunity.
H
Td – After primary vaccination, Td booster is recommended every 10 years. If unvaccinated WFM, primary vaccination consists of 3
doses of Td; 4-6 weeks should separate the first and second doses; the third dose should be administered 6-12 months after the
second dose.
Tdap should replace a one time dose of Td for HCP aged 19 though 64 years who have not received a dose of Tdap previously. An
interval as short as 2 years or less from the last dose of Td is recommended for the Tdap dose.
I
All WFM who have occupational exposure to blood or other potentially infectious materials shall have a documented post vaccination
antibody to Hepatitis B virus, HBsAb (anti-HBs). Hepatitis B vaccine series is available to WFM. Non-responders should be
considered susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG
prophylaxis for any known or probable parenteral exposure to HBsAg positive blood.
J
Seasonal influenza is offered annually to WFM when the vaccine becomes available.
This form and its attachment(s), if any, such as medical records shall be maintained and filed at non-DHS/non-County workforce
member’s School/Employer. The School/Employer shall verify completeness of DHS-Employee Health Services (EHS) form(s) and
ensure confidentiality of non-DHS/non-County WFM health information.
Upon request by DHS-EHS, the non-DHS/non-County WFM School/Employer shall have this form and its attachment(s) readily
available within four (4) hours.
All workforce member health records are confidential in accordance with federal, state and regulatory requirements.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or
requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we
are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by
GINA, includes an individual’s family medical history, the results of an individual’s family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family
member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. 29 C.F.R. Part 1635
EMPLOYEE HEALTH SERVICES
DECLINATION FORM
FOR NON-DHS/NON-COUNTY WFM
FIRST, MIDDLE NAME:
BIRTHDATE:
E or C #:
HOME/CELL PHONE #:
DHS FACILITY:
DEPT/WORK AREA/UNIT:
JOB CLASSIFICATION:
NAME OF SCHOOL/EMPLOYER/AGENCY/SELF:
AGENCY CONTACT PERSON:
AGENCY PHONE #:
CONTINUE ON NEXT PAGE
K-NC
Please check in the section(s) as apply AND indicate reason for the declination.
I. 8 CCR §5199. Appendix C1 - Vaccination Declination Statement (Mandatory)
Check as apply: Measles Mumps Rubella Varicella Td/Tdap
I understand that due to my occupational exposure to aerosol transmissible diseases, I may be at
risk of acquiring infection as indicated above. I have been given the opportunity to be vaccinated
against this disease or pathogen at no charge to me. However, I decline the above vaccination(s)
at this time. I understand that by declining the vaccine(s), I continue to be at risk of acquiring the
above infection(s), a serious disease. If in the future I continue to have occupational exposure to
aerosol transmissible diseases and want to be vaccinated, I can receive the vaccination(s) from
DHS-Employee Health Services (EHS) at no charge to me.
Reason for declination:
Seasonal Influenza: I am aware that I will be required to wear a surgical mask whenever I have
to work within 3 feet of a patient during influenza season.
Reason for declination (check as apply):
I am allergic to vaccine components. I don’t believe I need it.
I believe I can get the flu if I get the shot. I’m concerned about vaccine safety.
I am concerned about vaccine side effects. I do not like needles.
It’s against my personal belief. Other:
II. 8 CCR §5193. Appendix A-Hepatitis B Vaccine Declination (Mandatory)
Hepatitis B
I understand that due to my occupational exposure to blood or other potentially infectious material
(OPIM), I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the
opportunity to be vaccinated with Hepatitis B vaccine, at no charge to me. However, I decline
Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at
risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational
NON-DHS/NON-COUNTY WORKFORCE MEMBER GENERAL CONSENT
PAGE 2 OF 2
LAST NAME
FIRST, MIDDLE NAME
BIRTHDATE
HSN NO.
Rev 06/2014
T1-NC
exposure to blood or OPIM and I want to be vaccinated with Hepatitis B vaccine, I can receive the
vaccination series from DHS-EHS at no charge to me.
Reason for declination:
III. Specialty Surveillance Declination (Mandatory)
Check as apply: Asbestos Hazardous/Anti-Neoplastic Drugs Other:
I understand that due to my occupational exposure as indicated above, I am eligible and have
been given the opportunity to enroll in the Medical Surveillance Program. This will enable me to
receive specific initial, periodic and exit medical examinations for the hazard identified above, at
no charge to me and at a reasonable time and place.
However, I decline to be enrolled in this program at this time. I understand that by declining this
enrollment, I will not be medically monitored for occupational exposure to this hazard. I
understand that it is strongly recommended that I complete a medical questionnaire or
examination.
I also understand that if in the future I continue to have occupational exposure to the
hazard identified above and I want to be enrolled in the Medical Surveillance Program, I can do so
at any time at no charge to me.
Reason for declination:
SIGN BELOW
By signing this, I am declining as indicated on this form.
EMPLOYEE SIGNATURE
DATE
EHS STAFF (PRINT NAME)
SIGNATURE
DATE
EMPLOYEE HEALTH SERVICES
CONFIDENTIAL
NON-DHS/NON-COUNTY WORKFORCE MEMBER
8 CCR SECTION 5199 – APPENDIX B
ATD RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE
CONTINUE ON NEXT PAGE
GENERAL INFORMATION on last page
COMPLETE ONCE EVERY FOUR (4) YEARS OR AS NEEDED
This Appendix is Mandatory if the Employer chooses to use a Respirator Medical Evaluation Questionnaire other
than the Questionnaire in Section 5144 Appendix C (Form O-NC).
To the PHYSICIAN OR LICENSED HEALTH CARE PROFESSIONAL: Answers to questions in Section 1, and to
question 6 in Section 2 do not require a medical examination. Workforce member must be provided with a confidential
means of contacting the health care professional who will review this questionnaire.
To the WORKFORCE MEMBER: Can you read and understand this questionnaire (check one): Yes No
Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place
that is convenient to you. To maintain your confidentiality, 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
care professional who will review it.
Please complete this questionnaire in PEN and present to the staff at the examination clinic. To protect your
confidentiality, it should not be given or shown to anyone else. On the day of your appointment, you must bring a
valid driver’s license or other form of identification which has both your photograph and signature.
SECTION 1
The following information must be provided by every workforce member who has been selected to use any type of
respirator.
PLEASE PRINT LEGIBLY
TODAY’S DATE:
LAST NAME
FIRST, MIDDLE NAME
BIRTHDATE
GENDER
MALE
FEMALE
HEIGHT
FT
IN
WEIGHT
LBS
JOB TITLE
HSN NO.
PHONE NUMBER
Best Time to reach you?
Has your employer told you how to contact the health
care professional who will review this questionnaire?
Yes No
Check type of respirator you will use (you can check more than one category):
N, R, Or P disposal respirator (filter-mask, non-cartridge type only)
Other type (specify):
Have you worn a respirator?
Yes No
If “yes”, what type:
SECTION 2
Questions 1 through 6 below must be answered by every workforce member who has been selected to use any type of
respirator (please check “YES”, “NOT SURE” or “NO”).
YES
NOT
SURE
NO
1.
Have you ever had the following conditions?
a.
Allergic reactions that interfere with your breathing?
P-NC
Questionnaire for N95 Respirator
ATD RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE
Page 2 of 4
LAST NAME
FIRST, MIDDLE NAME
BIRTHDATE
HSN NO.
PHYSICIAN OR LICENSED HEALTH CARE PROFESSIONAL TO COMPLETE NEXT PAGE
P-NC
YES
NOT
SURE
NO
If “yes,” what did you react to?
b.
Claustrophobia (fear of closed-in places)
2.
Do you currently have any of the following symptoms of pulmonary or lung illness:
a
Shortness of breath when walking fast on level ground or walking up a slight hill or incline
b.
Have to stop for breath when walking at your own pace on level ground
c.
Shortness of breath that interferes with your job
d.
Coughing that produces phlegm (thick sputum)
e.
Coughing up blood in the last month
f.
Wheezing that interferes with your job
g.
Chest pain when you breath deeply
h.
Any other symptoms that you think may be related to lung problems:
3.
Do you currently have any of the following cardiovascular or heart symptoms?
a.
Frequent pain or tightness in your chest
b.
Pain or tightness in your chest during physical activity
c.
Pain or tightness in your chest that interferes with your job
d.
Any other symptoms that you think may be related to heart problems:
4.
Do you currently take medication for any of the following problems?
a.
Breathing or lung problems
b.
Heart trouble
c.
Nose, throat or sinuses
d.
Are your problems under control with these medications?
5.
If you’ve used a respirator, have you ever had any of the following problems while respirator is
being used? (If you’ve never used a respirator, check the following space and go to question 6).
a.
Skin allergies or rashes
b.
Anxiety
c.
General weakness or fatigue
d.
Any other problem that interferes with your use of a respirator
6.
Would you like to talk to the health care professional about your answers in this questionnaire?
Workforce Member Signature
Date
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.
To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical
information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s
family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services. 29 C.F.R. Part 1635
ATD RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE
Page 3 of 4
LAST NAME
FIRST, MIDDLE NAME
BIRTHDATE
HSN NO.
P-NC
FOR COMPLETION BY A PHYSICIAN OR LICENSED HEALTH CARE PROFESSIONAL
PROVIDE A COPY OF THIS PAGE TO THE WORKFORCE MEMBER
Part 1: Fit Testing Recommendation – Based on Questionnaire
Questionnaire above reviewed.
Medical Approval to Receive Fit Test
1. Disposable Particulate Respirators (N95)
2. Replaceable Disposable Particulate Respirator a. Half-Facepiece b. Full Facepiece
3. Powered Air-Purifying Respirators (PAPRs) a. Tight Fitting
4. Self-Contained Breathing Apparatus (SCBA)
Recommended time period for next questionnaire:
4 years
Other
with justification
Date Completed:
Next Due Date:
Any recommended limitations for respirator use on workforce member:
The above workforce member has not been cleared to be fit tested for a respirator.
Additional medical evaluation is needed. Physician or Licensed Health Care Professional to complete Part 2
below.
Medically unable to use a respirator.
Informed workforce member of the results of this examination.
Comments:
Part 2: Additional Medical Evaluations NOT APPLICABLE
Medical evaluation completed.
Medical Approval to Receive Fit Test
1. Disposable Particulate Respirators (N95)
2. Replaceable Disposable Particulate Respirator a. Half-Facepiece b. Full Facepiece
3. Powered Air-Purifying Respirators (PAPRs) a. Tight Fitting
4. Self-Contained Breathing Apparatus (SCBA)
Recommended time period for next questionnaire:
4 years
Other
with justification
Date Completed:
Next Due Date:
Any recommended limitations for respirator use on workforce member:
Medically unable to use a respirator.
Informed workforce member of the results of this examination.
Comments:
Physician or Licensed Health Care Professional Signature:
Print Name:
Date:
Time:
Facility Name/Address:
Phone No.
ATD RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE
Page 4 of 4
LAST NAME
FIRST, MIDDLE NAME
BIRTHDATE
HSN NO.
REV 06/2014
P-NC
GENERAL INFORMATION
THIS QUESTIONNAIRE IS TO BE REVIEWED BY A PHYSICIAN OR LICENSED HEALTH CARE PROFESSIONAL.
8 CCR §5199
Medical evaluation: DHS-EHS or non-DHS/non-County workforce member (WFM) School/Employer shall provide a medical evaluation,
in accordance with 8 CCR §5144(e) of these orders, to determine the workforce member’s (WFM) ability to use the respirator before the
WFM is fit tested or required to use the respirator. For WFM who use respirators solely for compliance with subsections (g)(3)(A) and
subsections (g)(3)(B), this alternate questionnaire may be used.
8 CCR §5144(e)
1. General. DHS-EHS or non-DHS/non-county WFM School/Employer shall provide a medical evaluation to determine the WFM’s
ability to use a respirator, before the WFM is fit tested or required to use the respirator in the workplace. DHS-EHS may
discontinue a WFM’s medical evaluations when the WFM is no longer required to use a respirator.
2. Medical evaluation procedures.
a. DHS-EHS or non-DHS/non-County WFM School/Employer shall identify a physician or other licensed health care
professional (PLHCP) to perform medical evaluations using a medical questionnaire or an initial medical examination that
obtains the same information as the medical questionnaire.
b. The medical evaluation shall obtain the information requested by this questionnaire in Sections 1 and 2, Part A.
3. Follow-up medical examination.
a. DHS-EHS or non-DHS/non-County WFM School/Employer shall ensure that a follow-up medical examination is provided
for a WFM who gives a positive response to any question among questions 1 through 8 in Section 2, Part A of this
questionnaire or whose initial medical examination demonstrates the need for a follow-up medical examination.
b. The follow-up medical examination shall include any medical tests, consultations, or diagnostic procedures that the
PLHCP deems necessary to make a final determination.
If WFM is unable to be fit-tested or has failed the fit test, WFM must be provided with a powered air-purifying respirator (PAPR).
This form and its attachment(s), if any, such as health records shall be maintained and filed at non/DHS/non-County WFM
School/Employer. The School/Employer shall verify completeness of DHS-EHS form(s) and ensure confidentiality of non-DHS/non-
County WFM health information.
Upon request by DHS-Employee Health Services (EHS), the non-DHS/non-County WFM School/Employer shall have this form and its
attachment(s) readily available within four (4) hours.
All workforce member health records are confidential in accordance with federal, state and regulatory requirements.
Health records will be maintained by DHS-EHS or non-DHS/non-County WFM School/Employer and kept for thirty (30) years after the
workforce member's employment/assignment ends, in accordance with State and Federal medical records standards and DHS policies
and procedures.
DHS-EHS will obtain the workforce member's written authorization before using or disclosing medical information, include to self, unless
the disclosure is required by State or Federal law such as to a public health authority or governmental regulatory agency.
Workforce members have the right to access their medical records and obtain a copy, thereof,
within fifteen (15) days after the request.
A copy of the respiratory protection regulation Title 8 CCR §5144 and §5199 can be found at
http://www.dir.ca.gov/title8/5144.html and http://www.dir.ca.gov/Title8/5199.html
EMPLOYEE HEALTH SERVICES
RESPIRATORY FIT TEST RECORD
FOR NON-DHS/NON-COUNTY WFM
FIRST, MIDDLE NAME:
BIRTHDATE:
E or C #:
HOME/CELL PHONE #:
DHS FACILITY:
DEPT/WORK AREA/UNIT:
JOB CLASSIFICATION:
NAME OF SCHOOL/EMPLOYER/AGENCY/SELF:
AGENCY CONTACT PERSON:
AGENCY PHONE #:
CONTINUE ON NEXT PAGE
N-NC
RESPIRATOR, QUESTIONNAIRE, MEDICAL EVALUATION
EQUIPMENT TYPE:
N95
MANUFACTURER:
Kimberly-Clark
MODEL: PFR95-174
PFR95-170
SIZE: Small
Regular
Based on review of the respirator health questionnaire: 8 CCR §5144 (Form O-NC) OR 8 CCR §5199 (Form P-NC), this
individual is:
Medically approved for only the following types of respirator subject to satisfactory fit test:
1. Disposable Particulate Respirators
2. Replaceable Disposable Particulate Respirators: a. Half-Facepiece b. Full-Facepiece
3. Powered Air Purifying Respirators (PAPRs): a. Tight Fitting
4. Self-Contained Breathing Apparatus (SCBA)
Recommended time period for next questionnaire:
4 years
Other
with justification
Date Completed:
Next Due Date:
List any facial fit problem conditions that apply to you (e.g., beard growth, sideburns, scars, deep wrinkles):
TASTE THRESHOLD SCREENING (NO food, drink, smoke, gum X 15 minutes before testing)
(Bitrex or Saccharin): X 10 X 20 X 30 Fail
RESPIRATOR FIT, PRESSURE FIT CHECK, COMFORT
ATTEMPT #1
ATTEMPT #2
ATTEMPT #3
Fit Check:
POSITIVE and/or
Pass Fail
Pass Fail
Pass Fail
NEGATIVE pressure
Pass Fail
Pass Fail
Pass Fail
Overall Comfort Level
Pass Fail
Pass Fail
Pass Fail
Ability to Wear Eyeglasses
Pass Fail NA
Pass Fail NA
Pass Fail NA
FIT TEST
ATTEMPT #1
ATTEMPT #2
ATTEMPT #3
Normal Breathing (performed for one minute)
Pass Fail
Pass Fail
Pass Fail
Deep Breathing (performed for one minute)
Pass Fail
Pass Fail
Pass Fail
Turning Head Side to Side (performed for one minute)
Pass Fail
Pass Fail
Pass Fail
Moving Head Up and Down (performed for one minute)
Pass Fail
Pass Fail
Pass Fail
Talking – Rainbow Passage (performed for one minute)
Pass Fail
Pass Fail
Pass Fail
Bending Over (performed for one minute)
Pass Fail
Pass Fail
Pass Fail
Normal Breathing (performed for one minute)
Pass Fail
Pass Fail
Pass Fail
NON-DHS/NON-COUNTY WORKFORCE MEMBER GENERAL CONSENT
PAGE 2 OF 2
LAST NAME
FIRST, MIDDLE NAME
BIRTHDATE
HSN NO.
Rev 06/2014
T1-NC
COMMENTS:
Workforce member failed fit testing. A powered air-purifying respirator (PAPR) will be provided to workforce member.
WFM trained on PAPR use. N/A
PASS Pre-Placement FIT Test on:
PASS Annual FIT Test on:
ACKNOWLEDGMENT OF TEST RESULTS
I have undergone fit testing on the above respirator. I have been instructed in and understand the proper fitting, use and care of the
respirator.
WORKFORCE MEMBER SIGNATURE:
WORKFORCE PRINT NAME:
DATE:
TIME:
FIT TEST TRAINER SINGNTURE:
FIT TRAINER PRINT NAME:
DATE:
TIME:
GENERAL INFORMATION
Pursuant to Title 8 of the California Code of Regulations, Sections 5144 and 5199 (8 CCR §5144 and §5199), all workforce member
(WFM) who are required to use respiratory protection must be fit tested with the same make, model, style, and size of respirator to be
used. Fit testing procedures for respirators must be conducted for the following:
Initial fit test must be conducted after the WFM has passed medical evaluation and clearance.
Newly hired/assigned workforce members who have passed medical evaluation and clearance.
When new style of respirator face piece is to be worn by WFM.
Annual fit test for all WFM required to wear a respirator.
WFM reports, or the Physician or Licensed Health Care Professional (PLHCP), supervisor, or Program Administrator
makes visual observations of changes in the workforce member’s physical condition that could affect respirator fit. Such
conditions include, but are not limited to, facial scarring, facial hair, dental changes, cosmetic surgery, or an obvious
change in body weight.
WFM must be given a reasonable opportunity to select a different respirator face piece and be re-fit tested, if required.
If WFM is unable to be fit-tested or has failed the fit test, WFM must be provided with a powered air-purifying respirator
(PAPR).
This form and its attachment(s), if any, such as medical records shall be maintained and filed at non-DHS/non-County WFM
School/Employer. The School/Employer shall verify completeness of DHS-Employee Health Services (EHS) form(s) and ensure
confidentiality of non-DHS/non-County WFM medical information.
Upon request by DHS-EHS, the non-DHS/non-County WFM School/Employer shall have this form and its attachment(s) readily
available within four (4) hours.
All workforce member health records are confidential in accordance with federal, state and regulatory requirements.
DHS-EHS will obtain the workforce member's written authorization before using or disclosing health information, include to self, unless
the disclosure is required by State or Federal law such as to a public health authority or governmental regulatory agency.
Workforce members have the right to access their medical records and obtain a copy, thereof,
within fifteen (15) days after the request.
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PrePlacement-NonCounty Welcome to Los Angeles County, Department of Health Services

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Completed 9 May 2020

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