OCCUPATIONAL HEALTH PROGRAM
MEDICAL CLEARANCE PACKET
SECTION I: INITIAL QUESTIONNAIRE
(TO BE COMPLETED BY APPLICANT)
Received by OHP- Date/Initials:
________________________________
This form and any medical evaluations are to determine physical and mental
___ability to perform your role and
whether the role might pose a risk to you. It is important that you provide complete information.
Complete, print and sign Section I. Submit with a copy of immunization and/or titer records in a sealed
envelope marked “OHP/CONFIDENTIAL” to Research Compliance (Room B157).
Please complete the form in Microsoft Word. Use “Tab” to move among fields. If you need additional space, use
a separate page labeled with your name, employee number and the question being answered.
Please contact ohp@qatar-med.cornell.edu or 4492 8434 with any questions.
1. PERSONAL DATA
Name
Employee #
Department
Gender
HC #
Mobile #
Job Title
Date of Birth
Lab PI
Date of Arrival in Qatar
City & Country of Residence Prior to Qatar
2. WORKPLACE EXPOSURE
Please check those items you will have contact with because of your work at WCMC-Q.
Animals
Infectious agents
Class III or IV laser
Human fluids/tissues
Animal fluids/tissues
Chemotherapeutic agents
Patients/
Research Subjects
Radiation or radioactive
materials
Other:
3. EXPOSURE DETAILS
For each item checked in Section 2, please provide the following information.
Type (e.g., animal species)
Frequency of Exposure
Duration of Each Exposure
4. ANIMAL EXPOSURE OUTSIDE WCMC-Q
Complete this section only if you checked “Animals” in Section 2 above.
a.
b.
Do you have regular exposure to any animals outside the workplace, such as pets or farm animals?
Yes
No
If you answered “Yes” above please describe the types of animals and your exposure to them:
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OCCUPATIONAL HEALTH PROGRAM
MEDICAL CLEARANCE PACKET
Name:
Employee #:
HC #:
5. WORKPLACE HAZARD EXPOSURE HISTORY
a.
b.
Have you needed medical attention or advice related to previous exposures to hazardous materials (including but
not limited to, radiation, chemicals, animals, or human or animal tissues), or incidents (such as fire or smoke/fume
inhalation)?
Yes
No
If you answered “Yes” above please describe the exposure and the attention/advice needed.
6. GENERAL MEDICAL INFORMATION
Question
Yes/No
Details (if Yes)
a.
Have you ever had a work-related injury or
illness?
Yes
No
b.
Do you regularly use any tobacco products?
Yes
No
List types, how often/how much, and how
many years:
c.
If you answered “No” to question b above,
have you regularly used any tobacco products
in the past?
Yes
No
List types, how often/how much, for how
many years, and when quit:
d.
Do you drink alcohol?
Yes
No
Weekly amount:
e.
Have you traveled outside Qatar in the past 12
months?
Yes
No
List the countries and trip duration(s):
f.
Are you/your partner pregnant or planning to
become pregnant?
Yes
No
g.
Do you have any physical conditions affecting
your ability to perform duties or use personal
protective equipment?
Yes
No
7. MEDICATION USE
Yes
No
Do you routinely use any medications (including prescription medications, over-the-counter products,
alternative therapies, herbal remedies and health supplements)? If yes, provide details below.
Name
Version Date: August 28, 2013
Dosage
(Amount & Frequency)
Purpose
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MEDICAL CLEARANCE PACKET
Name:
Employee #:
HC #:
8. IMMUNIZATION AND INFECTIOUS DISEASE HISTORY
Please indicate which of the following vaccines and/or illnesses you have had and the approximate dates or ages at
which you had them.
Vaccine/Illness
Vaccine?
Illness?
Date(s)/Age(s)
Tetanus
Diphtheria
Whooping Cough (Pertussis)
Measles (Rubeola)
German Measles (Rubella)
Mumps
Influenza
Smallpox
Chickenpox/Shingles (Varicella)
Rabies
Hepatitis A
Hepatitis B
Hepatitis C
Tuberculosis
Anthrax
9. ALLERGIES AND/OR SENSITIVITIES
Yes
No
Do you have any known allergies and/or sensitivities to latex (rubber products) or any medications,
animals, chemicals, foods or plants?
If yes, provide details below.
Substance
Symptoms
Version Date: August 28, 2013
Treatment/Preventive Measures
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OCCUPATIONAL HEALTH PROGRAM
MEDICAL CLEARANCE PACKET
Name:
Employee #:
HC #:
10. REVIEW OF SYSTEMS
Please review the following and check any that you are currently experiencing or have recently experienced.
General
Endocrine
Skin
Change in sleep habits
Heat or cold intolerance
Easy bruising
Chills or fever
Excessive thirst/hunger
Persistent rash
Fatigue/weakness
Swelling in groin or armpit
Swollen glands
Poor healing
Immunological
Depressed immune system
Heart
Changes in moles or bumps
Lungs
Chest pain or tightness
Cough/wheezing
Vision changes
Irregular heart beat
Shortness of breath
Hearing changes
Heart murmur
Ears/Eyes
Heartburn unrelated to eating
Vascular
Leg cramps
Bones & Joints
Phlebitis
Neurological
Dizziness
Fainting
Abdomen
Change in bowel habits
Abdominal pain
Back pain/injury/ surgery
Diarrhea
Limited motion
Jaundice
Pain, stiffness, swelling
Ulcer disease
Oral
Nose/Sinus
Headaches
Metallic taste
Infections
Memory loss
Mouth sores not healing
Loss of smell
Numbness/tingling
Tremors
Psychiatric
Mood swings
Nose bleeds
Congestion but no cold
Difficulty concentrating
Depression
11. MEDICAL CONDITIONS
Please review the following and check any that you have ever experienced.
Anemia
Angina
Arrhythmia
Asthma
Blood transfusions
Cancer
Claustrophobia
Chest injury/surgery
Chronic bronchitis
Diabetes
Emphysema
Epilepsy/seizures
Heart attack
Hernia
High blood pressure
Kidney disease
Liver disease
Lung disease
Malaria
Rheumatic fever
Skin rashes
Spinal/disk injury
Thyroid disease
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OCCUPATIONAL HEALTH PROGRAM
MEDICAL CLEARANCE PACKET
Name:
Employee #:
HC #:
12. MEDICAL CARE
Question
Yes/No
Details (if Yes)
a.
Are you seeing or have you seen a physician
or other healthcare provider for the item(s)
checked in Sections 7 through 10?
Yes
No
b.
Have you ever been hospitalized or had an
operation?
Yes
No
If yes, when and for what?
c.
Have you ever been treated or evaluated by a
mental health professional?
Yes
No
If yes, when and for what?
d.
Have you ever had a skin test (PPD/Mantoux)
for tuberculosis?
Yes
No
If yes, when?
e.
Have you ever tested positive for
tuberculosis?
Yes
No
If yes, when?
f.
If you indicated in Section 7 that you have
received the Hepatitis B vaccine:
 Did you have a complete series?
Yes
No
 Did you have a positive antibody titer?
Yes
No
13. SIGNATURE
Please read the following information carefully and sign below.
This form and any needed medical evaluations are required to determine your physical and mental ability to perform
your role and whether your role might pose a risk to you. Completion of Occupational Health Program requirements is
not a substitute for regular medical care.
Employment or affiliation depends upon full disclosure of all your medical and mental health information. Any false or
misleading statements can lead to dismissal.
Healthcare professionals will assess the information you provide and examine and treat you (and/or recommend
appropriate treatment and/or evaluation). The healthcare professionals might be from WCMC-Q or Qatar Foundation
(QF) or from another organization on behalf of WCMC-Q or QF.
These professionals will maintain medical records about you. Occupational health professionals have an ethical
obligation to protect the confidentiality of these records and avoid unauthorized disclosure. Information from these
records may be released within WCMC or WCMC-Q when relevant to safe performance of your duties, to other
healthcare providers for treatment purposes, or as required by law.
By signing below, I certify that:
 I understand the above information and authorize needed evaluations.
 My answers about my present or past health are complete and true to the best of my knowledge.
 I authorize the use of my health information as described above.
SIGNATURE:
Version Date: August 28, 2013
DATE:
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OCCUPATIONAL HEALTH PROGRAM
MEDICAL CLEARANCE PACKET
SECTION II: MINIMUM REQUIREMENTS
(FOR REVIEW BY CLINIC)
INSTRUCTIONS:
 Review Section I
 Review the information below according to type of exposure (see Section I)
 Complete indicated procedures and document results in Section III
Non-Animal Care Staff with Animal Contact
Procedure
Minimum
Frequency
Animal Care/
EHS Staff
Medical History/
Questionnaire
Initial & Annual


Physical
Exam
Initial


As Indicated

Tetanus/ Diphtheria/
Pertussis Vaccine1
Every 10 years




Hepatitis B2
Initial
3
As Indicated
Hearing Test
Initial & Annual

4
Spirometry/
OSHA Questionnaire5
Initial & Annual
As Indicated
Rodent/
Aquatics Users
Hazard/Agent
Dependent
Facilities

As Indicated

= Required (unless footnotes indicate otherwise)
As Indicated = based on assessment or review of medical history
1
Determined by medical history
Offered but not required. Employee must sign waiver if vaccination is declined.
3 Only rodent users where xenografts are performed/used
4 For staff working in areas with >85dBA noise levels (e.g., employees with cage wash duties)
5 Determined by medical history (e.g., lab animal allergies, hazardous agent use)
2
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OCCUPATIONAL HEALTH PROGRAM
MEDICAL CLEARANCE PACKET
SECTION III: EXAMINATION
(TO BE COMPLETED BY CLINIC)
INSTRUCTIONS:
 Conduct procedures indicated by your review of Sections I and II
 Complete this section
 Return this form to OHP or patient (with copies of lab results and vaccination records)
Name:
Employee #:
HC #:
EXAMINATION DATE:
MEDICAL AND PSYCHIATRIC HISTORY:
REVIEW OF SYSTEMS (INCLUDE UNEXPLAINED FEVER, RASH, COUGH, DIARRHEA, DIFFICULTY
BREATHING):
ALLERGIES (INCLUDING LATEX):
MEDICATIONS:
FAMILY HISTORY:
SOCIAL HISTORY:
HEALTH MAINTENANCE:
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OCCUPATIONAL HEALTH PROGRAM
MEDICAL CLEARANCE PACKET
Name:
Employee #:
HC #:
Height:
Weight:
BP:
Pulse:
Temp:
Vision Left:
20/
Vision Right:
20/
Both Eyes:
20/
Corrected:
Yes / No
Color Vision:
Pass / Fail
General Appearance
Normal
Abnormal
Comments
Skin
HEENT
Neck/Thyroid/Carotid pulses
Lungs/Chest
Heart
Abdomen/Inguinal
Extremities/Joints
Spine/Back/ROM
Neurological/Gait
IMPRESSION:
ADDITIONAL TESTS/PROCEDURES PERFORMED:
ADDITIONAL RECOMMENDATIONS:
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OCCUPATIONAL HEALTH PROGRAM
MEDICAL CLEARANCE PACKET
Name:
Employee #:
HC #:
DISPOSITION:
Continued clearance for duty requires freedom from any physical or mental health impairment
which is of potential risk to the employee or others or which might interfere with the continued
performance of duties, including the habituation or addiction to depressants, stimulants, narcotics,
alcohol or other drugs or substances, which may alter behavior.
Based on the information provided and the results of indicated evaluations and procedures, I
determine that the above-named individual is:
Cleared for Duty
Not Cleared for Duty
Cleared with Restrictions
Respirator Clearance
COMMENTS:
Name/Stamp:
Signature:
Date:
FOR OHP USE ONLY
Complete packet includes following attachments:
Yes
N/A
QA Needed
Date Sent:
Returned:
Result:
Copy to EH&S (p. 1 & this page only) Date Sent:
Copy to Research Compliance (p.1 & this page only) Date Sent:
Copy to Other (p.1 & this page only) Sent to:
Notify PI/Lab Manager
Date Done:
Follow-up needed before annual clearance
Date & Reason:
Reminders set for follow-up/annual clearance
Version Date: August 28, 2013
Date Sent:
Date Done:
Date(s):
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