"Communicator Applicant Medical History Form" - Oregon

Communicator Applicant Medical History Form is a legal document that was released by the Oregon Department of Public Safety Standards and Training - a government authority operating within Oregon.

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Download "Communicator Applicant Medical History Form" - Oregon

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Communicator Applicant Medical History
Employing Agency Information Only
This Applicant History and accompanying Medical Examination form is derived partially from the National Emergency Number
Association (NENA) Hearing Standards for Public Safety Telecommunicators , the 2015 Job Task Analysis for Telecommunicators, and
the National Highway Traffic Safety Administration Emergency Medical Dispatcher (EMD) National Standards Curriculum. It meets
the Americans With Disabilities Act (ADA) criteria to identify the Essential Functions/Tasks of the position. A physician developed the
medical standards based upon the essential tasks.
Critical and Essential Tasks are located at www.oregon.gov/dpsst/SC/pages/cjforms.aspx
This form is provided to employing agencies that do not have their own Medical Examination sheet. This is not a required document.
The F2Ta Final Medical Report and optional waiver are the only forms DPSST requires.
To be completed by applicant
Applicant Name (Last, First Middle)
Date of Birth (MM/DD/YYYY)
DPSST No.:
1. Do you have any current medical conditions?
Yes
No
If so, please list:
2. Have you had any prior medical conditions that required treatment?
Yes
No
If so, please list:
3. Have you ever had surgery?
Yes
No
If so, please list (include year of surgery):
4. Are you currently taking any medications? (prescribed or over the counter)
Yes
No
If so, please list:
Check if you have had any of the following.
Physician Comments
Headaches requiring treatment
Concussion or loss of consciousness
Seizures
Stroke
Other neurological conditions
Dizziness / balance problems
Memory problems
Depression / anxiety or other psychological conditions
Vision problems
. Currently wear glasses or contacts
Communicator Applicant Medical History
Employing Agency Information Only
This Applicant History and accompanying Medical Examination form is derived partially from the National Emergency Number
Association (NENA) Hearing Standards for Public Safety Telecommunicators , the 2015 Job Task Analysis for Telecommunicators, and
the National Highway Traffic Safety Administration Emergency Medical Dispatcher (EMD) National Standards Curriculum. It meets
the Americans With Disabilities Act (ADA) criteria to identify the Essential Functions/Tasks of the position. A physician developed the
medical standards based upon the essential tasks.
Critical and Essential Tasks are located at www.oregon.gov/dpsst/SC/pages/cjforms.aspx
This form is provided to employing agencies that do not have their own Medical Examination sheet. This is not a required document.
The F2Ta Final Medical Report and optional waiver are the only forms DPSST requires.
To be completed by applicant
Applicant Name (Last, First Middle)
Date of Birth (MM/DD/YYYY)
DPSST No.:
1. Do you have any current medical conditions?
Yes
No
If so, please list:
2. Have you had any prior medical conditions that required treatment?
Yes
No
If so, please list:
3. Have you ever had surgery?
Yes
No
If so, please list (include year of surgery):
4. Are you currently taking any medications? (prescribed or over the counter)
Yes
No
If so, please list:
Check if you have had any of the following.
Physician Comments
Headaches requiring treatment
Concussion or loss of consciousness
Seizures
Stroke
Other neurological conditions
Dizziness / balance problems
Memory problems
Depression / anxiety or other psychological conditions
Vision problems
. Currently wear glasses or contacts
Communicator Applicant Medical History
Employing Agency Information Only
Applicant Name (Last, First Middle)
Date of Birth (MM/DD/YYYY)
DPSST No.:
Check if you have had any of the following.
Physician Comments
. Eye surgery
. Difficulty driving or seeing at night
. Hearing loss / use of hearing aids
. Ringing in the ears
. Chest pain
. Heart attack
. Irregular / abnormal heart beats
. Heart murmurs
. Unusual shortness of breath
. Persistent diarrhea or constipation
. Blood in your stool
. Blood in your urine
. Coughing up blood
. Liver problems
. Kidney or bladder problems
. Unusual vaginal bleeding (if applicable)
. Hernia(s)
. Anemia
. Frequent bloody noses
. Easy bruising
. Cancer
. Unexplained weight changes
. Chronic fatigue
. Thyroid problems
. Diabetes
. Back or neck pain / injuries
. Muscle / ligament / joint injuries
. Broken bones
. Arthritis
. Illegal drug use
. Alcohol use
. Conviction(s) of driving under the influence
. Attended drug or alcohol rehabilitation
Communicator Medical Examination
Employing Agency Information Only Do Not Send to DPSST
Applicant Name: (Last, First Middle)
DOB: (MM/DD/YYYY)
DPSST No.:
Height:_________ ft. ________in.
Weight: _________ lbs. / _________ kg.
Eyes and Vision
Eye Exam (EOM, Pupils, etc.):
Normal:
Yes
No
1. Visual Acuity Standards
1.1. Corrected vision must be at least 20/30 (Snellen) when tested using both eyes together.
Right
Left
Both
Uncorrected
R20 /
L20 /
B20 /
Corrected
R20 /
L20 /
B20 /
2. Color Vision Standards
2.1. Applicant must be able to distinguish red, green, blue, and yellow, as determined by the HRR Test, 4th Edition.
2.2. Red or green deficiencies may be acceptable, providing the applicant can read at least nine of the first 13 plates of
the Ishihara Test.
2.3. Applicant who fails to meet the color vision standard may meet this standard by demonstrating they can correctly
discriminate colors via a field test conducted by the employer as approved by the examining physician/surgeon.
HRR Test, 4
th
Ed.:
Ishihara (if applicable):
Field Test (if applicable):
Comments:
Hearing
Ear Exam (External Canal, Tympanic Membrane, etc.)
Normal:
Yes
No
3. Hearing Acuity Standards
Telecommunciators, emergency medical dispatchers or applicants must meet the National Emergency Number
Association (NENA) hearing standard NENA-STA-007.2-2014 (June 14, 2014). Audiometric testing shall assess hearing
thresholds in each ear, determined using pure tone stimuli via air conduction with test frequencies including 500, 1000,
2000, 3000, 4000, and 6000 Hz.
3.1. Hearing thresholds at any evaluated frequency shall not exceed 25 dB HL in either ear. If hearing thresholds
exceed 25 dB HL at any evaluated frequency, binaural speech discrimination testing in quiet and noise shall be
completed in the sound field.
500 Hz
1000 Hz
2000 Hz
3000 Hz
4000 Hz
6000 Hz
Other
Right
Left
(if applicable)
Speech Discrimination Testing
The minimum acceptable standard of speech discrimination in quiet shall be a score no poorer than 90%
o
correct. The minimum acceptable standard of speech discrimination in noise shall be a score no poorer than
70% correct.
Use of hearing aids, cochlear implants or enhanced listening devices to achieve the speech discrimination
o
standards is permitted.
 Speech discrimination in quiet:___________
 Speech discrimination in noise:___________
Comments:
Communicator Medical Examination
Employing Agency Information Only Do Not Send to DPSST
Applicant Name:
DOB:
4. Medications Standard
The side effects of any prescribed medication must not interfere with the ability of the applicant to perform the critical
and essential tasks of the job.
Comments:
Laboratory*
* To be specified by agency requesting examination
Lab Work
Normal:
Comments
CBC
Yes
No
Chemistry Panel
Yes
No
Tuberculosis
Yes
No
Urinalysis / Drug Screen
Yes
No
Other:
Yes
No
Other:
Yes
No
NOTES: (Provide any additional information to the hiring agency regarding the applicant’s job-relevant functional
limitations, reasonable accommodation requirements, work restrictions, and a description of the nature and degree of
potential risks posed by the detected medical conditions. Include that information which is necessary and appropriate for
the hiring department in making hiring decision.)
I certify that I am a licensed physician or surgeon, have conducted an examination on the above-mentioned applicant, and
the information on this form is true and accurate.
Signature
License Number
Date
Printed Name: __________________________________ Phone Number: __________________________________
Address: ___________________________________________________________________________________
Please complete and return this Medical Exam, Applicant Medical History and the Form F2Ta Final Medical Report and
optional waiver to the requesting applicant or employing agency
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