Volume 1
Environmental, Health, and Safety Standards
01.13.24
Emergency Response Team Medical Evaluation
1.
Revision 0
March 2003
Page 1 of 17
PURPOSE
To define fitness for duty and medical surveillance requirements for personnel who respond to
actual or potential Air Products and Chemicals, Inc. chemical releases, fire situations or medical
emergencies. These requirements do not replace procedures in place for other processes that
have medical surveillance programs.
2.
SCOPE
The medical surveillance program must be instituted for Hazardous Materials (HazMat)
Technicians, Hazardous Materials (HazMat) Specialists, Fire Brigade Members, Emergency
Medical Service (EMS) personnel, Confined Space Rescue personnel and Hazardous Waste
Operations and Emergency Response (HAZWOPER) employees who are required to respond to
chemical releases, fire situations or medical emergencies. Vehicle recovery team members and
Emergency Coordinator/Administrators do not require any medical evaluation.
3.
SUMMARY
Each member of an emergency response team must receive the specified baseline medical
evaluation prior to initial assignment as an emergency responder. (4.1.1)
Each member of an emergency team must have the specified medical evaluation at intervals not
to exceed every 24 months. (4.1.1)
Medical evaluations must include a medical and a work history with emphasis related to the
handling of hazardous material. (4.2.1)
Medical evaluations must include assessment of the ability to wear any required personal
protective equipment (PPE). (4.2.2)
Medical evaluations and procedures must be performed by a licensed physician, or by a medical
practitioner who is under the supervision of a licensed physician, knowledgeable in occupational
medicine. (4.3.1)
The employee must provide the medical practitioner with all forms necessary to complete the
evaluation (4.4)
AUTHORIZATION
J. A. Herzstein, MD, MPH
Global Health and Wellness Director
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
Air Products and Chemicals, Inc., 2003
01.13.24, Rev. 0, Page 2 of 17
The Physician's/Medical Practitioner's Written Opinion (Form 5585) is kept in the employee file at
the facility. This form is the medical practitioner’s statement that the employee is cleared to be a
member of an emergency response team. No medical records are kept in the employee file. (4.5)
Medical records must be retained for 40 years from the end of employment. (4.7.2)
4.
ROLES AND RESPONSIBILITIES
It is the responsibility of the site manager or team leader to ensure that all medical evaluations
are performed in a timely manner and to track which employees have been determined to be fit
for emergency response duties.
It is the responsibility of the site manager to select the medical practitioner, with assistance from
Global Health and Wellness if needed.
It is the responsibility of the emergency response team member to report any injuries or illnesses
related to hazardous exposures, e.g., above permissible exposure limits without personal
protective equipment (PPE), to the site manager or team leader so that a medical evaluation can
be provided.
It is the responsibility of the site manager to provide this standard practice and forms to the
employee to take to the medical practitioner.

In the United States, the medical practitioner must return the evaluation information to Global
Health and Wellness, or where applicable, to the onsite Air Products’ medical department.

In non-United States locations, it is the site manager's responsibility to ensure that the
medical records are maintained at the offsite medical facility or as required by local
regulation. Only the Physician's/Medical Practitioner's Written Opinion (form 5585) is stored in
the employee's files. Medical information including diagnosis, symptoms, treatment and
examination results is not kept in the employee file.
4.1
Frequency of Medical Evaluations
4.1.1
Initial and Periodic Medical Evaluations

A baseline medical evaluation is required prior to assignment of an employee becoming an
emergency response team member.

If the employee has had an Air Products preplacement evaluation meeting all the
requirements of an emergency response medical evaluation within 24 months of assignment
to an emergency responders team, the preplacement evaluation may be used as a baseline
clearance evaluation at the discretion of the country supervisory occupational medical
practitioner (outside the U.S.) or Global Health and Wellness.

After the baseline evaluation, the employee must undergo a periodic medical evaluation at
intervals not to exceed every 24 months.

At termination of employment or resignation from an emergency response team.

When the company is notified by the employee that he has developed signs or symptoms
indicating possible overexposure to hazardous substances or health hazards.

When the employee has been injured during an emergency response.

If the employee has a significant change in health status, e.g., heart attack or newly
diagnosed diabetes.
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 3 of 17
4.2

When the employee has been over exposed to hazardous substances (at concentrations
above the permissible exposure limits or the published exposure levels) during an emergency
incident without the necessary PPE being used, or with the PPE used ineffectively.

At more frequent intervals if the medical practitioner determines that an increased frequency
of evaluations is necessary for medical reasons.
Content of Medical Evaluations
Medical evaluations must include a medical and work history with special emphasis on:
1) conditions related to the handling of hazardous materials,
2) fitness for duty, including the ability to wear required PPE, tolerate temperature
extremes and perform the physical work required
4.2.1
Medical and Work History
The employee must complete the Periodic Medical Health History – form 4093 (Attachment 5)
and the Health History Questionnaire for Respirator Users and Emergency Responders – form
4086 (Attachment 6).
The employee or facility manager must complete the top section of the Physician’s/Medical
Practitioner’s Written Opinion - form 5585 (Attachment 3) and the top section of the Emergency
Responder Medical Evaluation Record -form 5584-1 (Attachment 4) prior to the medical
evaluation.
The employee must discuss with the medical practitioner any concerns of inability to perform
emergency response duties.
4.2.2
Fitness for Duty
An evaluation of fitness for duty must be included in the medical evaluation. The evaluation must
include clinical judgment regarding the employee’s ability to don and wear PPE, including a
respirator, and to work under conditions, e.g., temperature extremes and physical demands that
may be expected during an emergency response.
The medical practitioner must perform the medical evaluation as specified by the Medical
Evaluation Content requirements (Attachment 2) of this standard.
The medical practitioner must complete the forms specified by this standard:
Physician's/Medical Practitioner's Written Opinion - form 5585 (Attachment 3)
Emergency Responder Medical Evaluation Record - form 5584-1 (Attachment 4)
The medical practitioner and the employee must discuss and document any concerns related to:
Periodic Medical Health History - form 4093 (Attachment 5)
Health History Questionnaire for Respirator Users and Emergency Responders - form
4086 (Attachment 6)
Worst Case Scenario - only required for HazMat Technicians and HazMat Specialists
(Attachment 7)
The employee must self-report or the supervisor must express concerns of any inability to
perform emergency response duties.
4.2.3
Information Provided to the Employee
The medical practitioner will discuss the results and findings of all parts of the evaluation with the
employee.
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 4 of 17
4.3
Evaluation by a Medical Practitioner and Costs of the Evaluation
4.3.1
Medical Practitioner Qualifications
All medical evaluations and procedures must be performed by a licensed physician, or under the
supervision of a licensed physician knowledgeable in occupational medicine. Medical
practitioners who may perform the evaluations include Nurse Practitioners, Physician Assistants,
or those properly licensed to do so as outlined in the EH&S Compliance Specification;
Qualifications of Occupational Health Professional Retained by Air Products and Chemicals, Inc.
(2.EHS.02.13.09.WW)
In the United States, the Global Health and Wellness Director is considered the supervisory
licensed medical practitioner. In non-United States locations, a regional supervisory licensed
occupational medical practitioner will be identified by Air Products.
The medical practitioner will determine the employee's medical clearance status, subject to
review and final approval by the Global Health and Wellness Director or Air Products supervisory
licensed occupational medical practitioner.
4.3.2
Cost and Accessibility of Medical Evaluations
The medical evaluation must be provided to the employee without cost or loss of pay during the
normal workday. The Air Products’ facility where the employee works is responsible for the cost
of the medical evaluation.
4.4
Information Supplied to the Medical Practitioner
The medical practitioner must be provided with:
 Letter to the Medical Practitioner (Attachment 1)
 a copy of this standard and all related forms (Attachments 2, 3, 4, 5, 6, 7)
 a description of the employee's duties including physical requirements and potential for
hazardous exposures
 a description of any personal protective equipment used or to be used
 in the United States, a copy of OSHA Regulations Standard - 29 CFR 1910.120
Hazardous Waste Operations and Emergency Response
The site manager or employee must complete the appropriate section of the Physician's/Medical
Practitioner's Written Opinion (form 5585) and Emergency Responder Medical Evaluation Record
(form 5584-1) prior to the medical evaluation. (Attachments 3 and 4)
4.5
Physician's/Medical Practitioner's Written Opinion
4.5.1
Contents of the Physician's/Medical Practitioner's Written Opinion (form 5585)
This form contains the following information:





The medical practitioner’s opinion as to whether the employee has any medical
conditions that would place the employee at increased risk of an adverse health outcome
from performing an emergency response or from wearing PPE.
The medical practitioner’s recommended work restrictions.
A statement that the employee has been informed by the medical practitioner of the
results of the medical evaluation and any medical conditions that may require further
evaluation or treatment.
The site manager must furnish a copy of this form to the employee if so requested.
The Physician's/Medical Practitioner’s Written Opinion must not reveal specific findings or
diagnoses unrelated to occupational exposures.
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 5 of 17
4.6
Tasks Requiring Respirators
Persons should not be assigned to tasks requiring respirators, including air supplied respirators,
unless it has been determined that they are physically able to perform the work and use the
equipment. All sites must comply with the global EH&S standard Respiratory Protection 01.13.10.
4.7
Record Keeping
4.7.1
Record Filing Process
Within the United States, the site manager is responsible for assuring that all medical records are
directed from the medical practitioner to Global Health and Wellness, or where applicable, to the
onsite Air Products medical department. In non-United States locations, it is the site manager's
responsibility to ensure that medical records are maintained with the medical practitioner or
according to global EH&S standard Management of Medical Records – 2.EHS.02.10.01.WW.
The facility retaining medical records of the medical evaluations will, when requested, and with
employee written permission, provide the medical practitioner with information from previous
medical evaluations of the employee. In addition, the medical practitioner is responsible for
furnishing Global Health and Wellness with the evaluation results and a copy of the
Physician's/Medical Practitioner's Written Opinion.
4.7.2
Required Duration of Record Retainment
Global Health and Wellness, the onsite Air Products medical department, or in non-U.S.
locations, the supervisory licensed medical practitioner, is responsible for maintaining an accurate
record of all emergency responders' medical clearance evaluations for 40 years from the end of
employment.
4.7.3
Information Required for Records
The record requirements will include at least the following information:




4.8
The name and social security number or other identifier, where applicable.
Medical practitioner’s written opinions, recommended work restrictions and results of
evaluations and tests.
Any employee medical complaints related to exposure to hazardous substances.
A copy of the job/exposure information provided by Air Products to the medical
practitioner.
Attached Forms
Attachment 1 - Letter to the Medical Practitioner
Attachment 2 - Medical Evaluation Content
Attachment 3 - Physician's/Medical Practitioner's Written Opinion (Form 5585)
NOTE: The site manager/employee completes the first section BEFORE medical
evaluation.
Attachment 4 - Emergency Responder Medical Evaluation Record (Form 5584-1)
Attachment 5 - Periodic Medical Health History (Form 4093)
Attachment 6 - Health History Questionnaire for Respirator Users and Emergency Responders
(Form 4086)
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 6 of 17
Attachment 7 - Worst Case Scenario (Only required for HazMat Technicians and HazMat
Specialists)
NOTE: These forms are for the employee/medical practitioner to reference and complete.
Current forms can be accessed through the Air Products’ Global Health and Wellness website.
5.
RELATED DOCUMENTS
OSHA 1910.120
NFPA
01.08.06
01.08.16
01.13.10
2.EHS.02.10.01.WW
2.EHS.02.13.09.WW
6.
Hazardous waste operations and emergency response (HAZWOPER)
Responders to Hazardous Materials Incidents
Emergency Response Team Training and Certification Requirements
Emergency Response Program
Respiratory Protection
Management of Medical Records
EH&S Compliance Specification; Qualifications of Occupational Health
Professional
Retained by Air Products and Chemicals, Inc
DEFINITIONS
First Responders Awareness Level are individuals who in the course of their normal duties may
be the first on the scene of an emergency involving hazardous materials.
First Responders Awareness Level are expected to recognize the presence of hazardous
materials or conditions, protect themselves from the hazardous materials, call for trained
personnel, and secure the scene, i.e., keep non-emergency response trained individuals away,
etc.
Emergency Medical Service (EMS) are personnel who respond to medical incidents, may be
required to wear medical PPE to protect themselves from body fluids. They will not be required to
wear additional PPE or go into contaminated atmospheres.
First Responders (HAZWOPER) Operations Level are individuals who initially respond to
conditions or releases or potential releases of hazardous materials for the purpose of protecting
nearby persons, the environment, or property from the effects of the release. They must be
trained to respond in a defensive fashion to control the release from a safe distance, keep it from
spreading, and prevent exposures. They are only required to wear minimal PPE, very rarely up
through Level B and work in non-exposed areas.
Hazardous Materials (HazMat) Technicians are individuals who respond to conditions or
releases or potential releases for the purpose of stopping or controlling the release for either onsite or off-site emergency responses. They are required to wear the most protective and
physically demanding PPE, up to and including Level A PPE. These individuals may be required
to work in IDLH atmospheres.
The duties of a Hazardous Materials (HazMat) Specialist parallel those of the Hazardous
Materials Technician. However, the Hazardous Materials Specialist duties require a more directed
or specific knowledge of various substances or conditions they may be called upon to contain.
They are required to wear the most protective and physically demanding PPE, up to and including
Level A PPE. These individual may be required to work in IDLH atmospheres.
Confined Space Rescue are individuals who are called upon to rescue personnel from a
confined space. These individuals may find it necessary to don the most protective PPE and
enter IDLH atmospheres.
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 7 of 17
Fire Brigade members are trained in fire fighting methods. They could be called upon to wear
PPE up to and including level B and work in IDLH conditions under physically demanding
conditions.
Level A – The hazardous substance has been identified and requires the highest level of
protection for skin, eyes and respiratory system based on either the measures (or potential for)
high concentration of atmospheric vapors, gases or particulates; or the site operations and work
functions involve a high potential for splash, immersion or exposure to unexpected vapors, gases
or particulates of materials that are harmful to skin or capable of being absorbed through the skin.
Level B – The type and atmospheric concentration of substances have been identified and
require a high level of respiratory protection, but less skin protection.
IDLH – Immediately Dangerous to Life or Health - An atmospheric concentration of any toxic,
corrosive, or asphyxiant substance that poses an immediate or delayed threat to life or would
interfere with an individual's ability to escape from a dangerous atmosphere. Note: Some materials hydrogen fluoride gas, for example - may produce immediate transient effects that, even if severe may pass without
medical attention, but are followed by sudden, possibly fatal collapse 12-72 hours after exposure. Such materials in
hazardous quantities are considered to be “immediately” dangerous to life or health.
PPE – Personal Protective Equipment – coveralls, gloves, boots, respirators, etc.
7.
REVISION SUMMARY
Rev.
P0
P1
P2
0
Date
January 2002
June 2002
March 2003
March 2003
Coordinator
D. L. Fisher
D. L. Fisher
P. Riola
P. Riola
Description of Revision
Draft
Draft - Attachments added
Extensive revisions
Approved
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 8 of 17
ATTACHMENT 1
Dear Medical Practitioner,
Thank you for being part of the Air Products and Chemicals, Inc. Emergency Response Team Medical Evaluation Program.
Our employee is being sent to you to be evaluated for fitness for hazardous material handling and emergency response.
The attached information has been designed to assist you in the determination of this employee's medical clearance or
denial.
The attached documents include:

A description of the employee's duties, including exposure levels or anticipated exposure levels and a description
of any personal protective equipment used. (Section 6 – titled Definitions)
United States only: A copy of OSHA Regulations Standard - 29 CFR Hazardous waste operations and
emergency response – 1910.120; as required by 1926.35.
Physician's/Medical Practitioner's Written Opinion (Form 5585)
Emergency Responder Medical Evaluation Record (Form 5584-1)
Periodic Medical Health History (Form 4093)
Health History Questionnaire for Respirator Users and Emergency Responders (Form 4086)
Medical Evaluation Content
For HazMat Technician/HazMat Specialist responders, the Worst Case Scenario (Attachment 7) must be
referenced when deciding if an employee can be associated with the duties of a HazMat Technician/ HazMat
Specialist.







Air Products best practices requires that the content of the physical evaluation include all the components indicated within the
Emergency Response Personnel – Medical Evaluation Content (Attachment 2).
The employee must be informed by you of the results of his/her medical evaluation and any other medical conditions which
require further evaluation or treatment. If during your evaluation you identify nonoccupational medical conditions that require
further evaluation, direct the employee to his/her personal physician.
In the United States, send the entire packet to Air Products Global Health and Wellness at the address listed below.
For non-United States locations, return only the Physician's/Medical Practitioner's Written Opinion to the
employee’s site of employment. Medical evaluation records must be retained by the medical practitioner.
Employee medical information must not be sent to non-medical personnel at Air Products facilities.
If you have any questions regarding the Emergency Response Team Medical Evaluation Program, please contact Air
Products Global Health and Wellness at healthun@apci.com or 610-481-8387.
Sincerely,
Jessica Herzstein, MD, MPH
Global Health and Wellness Director
Air Products and Chemicals, Inc.
7201 Hamilton Blvd.
Allentown, PA 18195-1501
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 9 of 17
ATTACHMENT 2
Emergency Response Personnel – Medical Evaluation Content
1. Vehicle recovery team members and Emergency Coordinator/Administrators, based on their role in an emergency, would
not require any medical evaluation.
2. EMS and HAZWOPER Operations would require a medical evaluation that evaluates general health but does not
stringently evaluate cardiac status.
3. HazMat Technicians/Specialists, Fire Brigade and Confined Space Rescue personnel will require a more rigorous medical
evaluation. The components of the two evaluations are as follows:
Timing of evaluation: Every employee is required to have a baseline evaluation before responding to an emergency. (Ideally,
prior to training.) In order to continue as a team member, the time between evaluations cannot exceed 24 months.
EMS and HAZWOPER Operations
HazMat Tech/Spec, Fire Brigade and Confined Space
Rescue
Medical history - The medical examiner must be given
details outlining the rigorous physical, mental and
emotional demands this employee may be subjected to
in an emergency.
Medical history - The medical examiner must be given
details outlining the rigorous physical, mental and
emotional demands this employee may be subjected to
in an emergency.
Height and Weight - The medical examiner must take into
consideration that obesity and lack of physical fitness do
increase cardiac risk.
Height and Weight - The medical examiner must take into
consideration that obesity and lack of physical fitness do
increase cardiac risk.
Blood Chemistries - Kidney, Liver and Lipid Panel and a
Complete Blood Count without differential.
Blood Chemistries - Kidney, Liver and Lipid Panel and a
Complete Blood Count without differential.
Urinalysis - Dipstick.
Urinalysis - Dipstick.
Spirometry - Lung Function Testing.
Spirometry - Lung Function Testing.
Blood Pressure - If the blood pressure is consistently above
150/90 mm Hg, further testing is recommended
to determine whether the employee is able to function in an
emergency situation.
Blood Pressure - If the blood pressure is consistently above
150/90 mm Hg, further testing is recommended to determine
whether the employee is able to function in an emergency
situation.
Vision Testing - Distant and near visual acuity of at least
20/40 feet, 6/12 meters or equivalent (Snellen) with or
without correction.
Vision Testing - Distant and near visual acuity of at least
20/40 feet, 6/12 meters or equivalent (Snellen) with or
without correction.
No hearing testing required
Hearing – Forced whisper voice not less than five feet or 1.5
meters or equivalent with or without the use of a hearing aid.
No additional cardiac testing required
Exercise Cardiac Evaluation:
1. Resting EKG, BP and pulse.
2. Apply typical emergency gear and respirator used
during an emergency. Full gear is recommended. At a
minimum employee must wear a respirator (e.g.,
SCBA, in-line hose), and pants.
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 10 of 17
Emergency Response Personnel – Medical Evaluation Content (continued)
3.
Exercise for three minutes (steps, running in place).
Stop. Record BP and pulse.
4.
Repeat Step 3.
5.
Quickly take off gear. Post exercise: EKG, BP and
pulse.
Any abnormalities (including the inability to complete the
test) warrant further evaluation and/or intervention.
Physical Evaluation - Evaluate : throat, heart murmurs
and arrhythmias, lungs, gastrointestinal system,
abdomen, abnormal masses, neurological, extremities,
spine. Include the evaluation for speech difficulties.
Physical Evaluation - Evaluate : throat, heart murmurs and
arrhythmias, lungs, gastrointestinal system, abdomen,
abnormal masses, hernia, neurological, extremities,
spine, musculoskeletal. Include the evaluation for speech
difficulties.
Required Profile Screenings
Term
Chem-Screen Profile
Definition
Glucose
Sodium
Potassium
Chloride
Blood Urea Nitrogen (BUN)
Creatinine
BUN/Creatinine Ratio
Cholesterol, Total
HDL Cholesterol
Complete Blood Count (without
differential)
White Blood Cell Count (WBC)
Red Blood Cell Count (RBC)
Hemoglobin (Hgb)
Hematocrit (Hct)
Mean Cell Volume (MCV)
Mean Cell Hemoglobin (MCH)
Mean Cell Hemoglobin Concentration (MCHC)
Red Cell Distribution Width (RDW)
Platelet Count (Plt)
Mean Platelet Volume (MPV)
One test within the pulmonary function testing which includes:
Forced Vital Capacity (FVC) – the maximum volume of air which can
be exhaled forcefully after maximal inspiration or the most one can
blow out after taking the deepest breath.
Forced Expiratory Volume in one second (FEV1) – the volume of air
exhaled during the first second of expiration.
Forced Expiratory Volume in one second as a percent of the Force
Vital Capacity (FEV1/FVC%).
Forced Mid-Expiratory Flow Rate (FEF 25-75% or MMEF 25-75%) –
the mean forced expiratory flow during the middle half of the FVC.
Spirometry




LDL Cholesterol
Triglycerides
Bilirubin, Direct
Bilirubin, Total
Alkaline Phosphatase
GGT
AST
ALT
LDH
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 11 of 17
ATTACHMENT 3
Physician’s / Medical Practitioner’s Written Opinion
(Fit for Duty Statement)
To be completed by APCI facility manager / employee before medical evaluation:
EMPLOYEE NAME
EMPLOYEE NUMBER
This is a Fitness for Duty evaluation for:
EMS or HAZWOPER Operations
HazMat Technician, HazMat Specialist, Fire Brigade, Confined Space Rescue
Other – explain:
To be completed by the examining medical practitioner
To comply with Air Products’ Best Practice Standards, the following must be completed and included in the employee’s records. The
employee shall be furnished a copy of this report by the employer. Do not reveal specific findings or diagnoses unrelated to
occupational exposure on this form.
Duties associated with the above job functions are defined in the attached Air Products global standard 01.08.17 - Emergency
Response Team Medical Evaluation.
The following are my recommendations and comments based upon this medical evaluation (select only one):
This examinee is medically cleared for the job functions listed above.
I have detected a medical condition which may preclude work listed above.
This examinee is cleared for the above job functions with the following restrictions:
RESPIRATOR USE (select only one):
No restrictions. Medically cleared for respirator use.
Not approved for respirator use.
Approved for respirator use only with the following restrictions:
For medical practitioners working within the United States: Return the completed medical evaluation results and this form to the
Air Products and Chemicals, Inc., Global Health and Wellness, 7201 Hamilton Blvd. Allentown, PA 18195. Submit charges for your
services to the local Air Products facility.
For medical practitioners working outside of the United States: Retain the completed medical evaluation results and this form in
your office. Forward a copy of this form to the local Air Products facility.
The examinee has been informed of the results of this medical evaluation and any medical conditions which require further examination
or treatment. This certification expires two years from date of issue unless otherwise specified, but in no case to exceed 24 months.
MEDICAL PRACTITIONER’S SIGNATURE
DATE
MEDICAL PRACTITIONER’S NAME PRINTED
MEDICAL PRACTITIONER’S TELEPHONE
To be completed by the employee
I have been informed by the above medical practitioner of the results of the medical evaluation and any other medical conditions
which require further examination or treatment.
EMPLOYEE SIGNATURE
DATE
FORM 5585 (2/03)
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 12 of 17
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 13 of 17
ATTACHMENT 5
Periodic Medical Health History
FOR OFFICE
USE ONLY
CYCLE YEAR
LOCATION
CYCLE CODE
P
T
TR
DOT
PE
HAZ
FC
Pilot
Other:
To be completed by employee
NAME (LAST, FIRST, MI)
SOCIAL SECURITY NUMBER
JOB TITLE
DEPARTMENT
LOCATION (CITY AND STATE)
DATE
IMMEDIATE SUPERVISOR
MAIL CODE
WORK HISTORY - Have you ever:
 Lost time from work, of at least 2 consecutive weeks or more in each instance, during the past 2 years due to injury or illness?
No
Yes, (specify each instance)

Traveled on business to countries other than Canada or Western Europe?

Worked with a respirator?
No
Yes, explain:

Been exposed to asbestos?
No
Yes, explain:

Been required to wear hearing protection?

Worked in jobs with heat exposure?

Worked in hazardous areas or with chemicals?
No
No
No
Yes (if yes, please complete International Traveler section on pg. 2)
Yes, explain:
Yes, explain:
No
Yes (see list below of Potential Occupational Environmental Hazards),
POTENTIAL OCCUPATIONAL ENVIRONMENTAL HAZARDS
(Note: This is a list of examples of potential occupational environmental hazards and is not all-inclusive. Please use abbreviations shown for hazards listed.)
ACE = Acetylenics
CHN = 1,1 Trichloroethane
FLU = Fluoride/Fluorine
MER = Mercury
ACN = Acrylonitrite
CHR = Chromates
FRM = Formaldehyde
MNG = Manganese
AKA = Alkylamines
CTP = Coal Tar Products
GAS = Irritant Gases (Misc.)
MTC = Methylene Chloride
AMM = Ammonia
CYN = Cyanide/Nitriles
ISO = Isocyanates (TDI, MDI)
NIK = Nickel
ARS = Arsine/Arsenic
DAB = Dabco and By-Products
LAB = Laboratory (Misc. Lab Chemicals)
NSE = Noise
ASB = Asbestos
DNT = Dinitro Toluene
LED = Lead
NST = Nuisance Dusts (including
BEN = Benzene
EMU = Emulsions
MDA = Methylenedianiline
rock wool)
CAD = Cadmium
FCS = Free Crystalline Silica
PVA = Polyvinyl Alcohol
FAMILY HISTORY
Have any blood relatives had:
Hypertension
Heart problems
Stroke
RAD = Radiation (x-rays, gamma)
TDA = Toluene Diamine
VCM = Vinyl Chloride Monomer
VNA = Vinyl Acetate
Cancer/leukemia
Diabetes
Who and which problem(s)?
PERSONAL HEALTH HISTORY
Allergies:
Current medications:
Date of last tetanus booster:
Do you wear seatbelts?
Do you exercise regularly?
No
Do you have problems sleeping?
Yes
Do you smoke?
No
Yes, how often?
Do you drink more than 16 oz. of caffeinated beverages daily?
No
No
Yes, times per week:
Yes, how much?
for how long?
Do you drink alcoholic beverages
No
No
Yes, how much?
Yes, how much?
Who is your family doctor?
Are you currently under a doctor’s care?
No
Yes, explain:
Have you had any hospitalization, surgery, serious illness, or injury?

No
Yes, explain:
PERSONAL HEALTH HISTORY CONTINUED ON BACK

FORM 4093 (REV. 9/02)
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 14 of 17
PERSONAL HEALTH HISTORY - CONTINUED
Have you had or are you presently experiencing any of the following conditions which require medical attention:
NEUROLOGICAL
HEART/BLOOD VESSELS
YES NO
YES NO
Migraines
Heart attack/angina/bypass
Frequent/severe headaches
Rheumatic fever/heart murmur
Fainting/dizzy spells
Palpitations/irregular heartbeat
Head injuries or concussions
High blood pressure
Epilepsy/seizures/convulsions
Pain/discomfort/tightness in chest
Unusual lack of energy
Leg cramps
Difficulty with speech
Varicose veins/embolisms/phlebitis
Stroke
YES
YES NO
Glaucoma
Pain/discomfort
Double/blurred/decreased vision
Eye injuries
EAR/NOSE/THROAT
YES NO
Frequent earaches
Drainage from ear/infections
Hearing loss/ringing in ears
Frequent nosebleeds/sinus problems
Frequent/severe sore throats
Persistent hoarseness
Teeth or gum problems
Difficulty swallowing
Frequent urination
Trouble starting/stopping urine
Blood in urine
Pain or burning on urination
NO
YES
NO
YES
NO
Depression/suicide attempts
Hepatitis/jaundice
Pain/discomfort in stomach
Ulcers/gall bladder disease
Constipation/diarrhea
Blood in stools
Colitis
Hernias
Hemorrhoids
Received blood products or organ
transplant prior to 7/92?
Nervous breakdowns
Anxiety/nerve problems
Bulimia/anorexia
OTHER
Anemia/bleeding disorders
Diabetes/hypoglycemia
MUSCULOSKELETAL/EXTREMITIES
Cancer/leukemia
YES
YES
NO
Arthritis
Pain/stiffness in joints
Weakness in arms or legs
Swelling of ankles or feet
Numbness/tingling in fingers/toes
Paralysis/loss of sensation in limbs
Swelling of fingers or hands
NO
Urinary infections
Viral infection/mononucleosis
LUNGS
Asthma/pneumonia/T.B.
Persistent cough/wheezing
Shortness of breath
Productive coughs (mucus, blood)
YES
Kidney stones
PSYCHIATRIC
ABDOMEN
EYES
GENITOURINARY
NO
Recent unexplained weight changes
Thyroid disorder
Persistent rash/skin disorders
Please explain any yes answers:
International Travelers: please explain any medical / social concerns you have regarding international travel that you wish to discuss:
FORM 4093 (REV. 9/02)
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 15 of 17
ATTACHMENT 6
Health History Questionnaire for Respirator Users
and Emergency Responder
NAME
EMPLOYEE NUMBER
WORK LOCATION / MAIL CODE
DATE OF BIRTH
JOB TITLE
WORK PHONE
SUPERVISOR
THIS QUESTIONNAIRE IS GIVEN BECAUSE OF (CHECK ALL THAT APPLY)
Respirator Use
Emergency Responder
Other, explain
Dear Employee,
Please answer the following questions to provide a basis to wear a respirator. Your supervisor must allow you to answer this questionnaire
during normal working hours, or at a time and place that is convenient to you. To maintain confidentiality, your supervisor must not look at
or review your answers. Please forward this completed questionnaire to the Medical Evaluation Coordinator for your location. Only a
decision concerning your ability to wear a respirator will be given to your supervisor. To comply with Air Products’ Best Practice Standards,
every employee who has been selected to use a respirator must complete in its entirety this health history questionnaire for medical
clearance. Medical clearance for respirator use is not required for those employees using a nuisance dust mask for comfort or an
air-supplied escape respirator for emergency escape purposes.
MEDICAL / SURGICAL HISTORY
1. Have you had any major illnesses since your last APCI physical examination?
If yes, explain:
2
Have you had any surgeries since your last APCI physical examination?
If yes, explain:
Yes
Yes
No
No
RESPIRATOR HISTORY
3. Type(s) of respirator(s) to be worn. Check all that apply
half face
full face
SCBA
Other, explain:
4. How often will/do you wear a respirator?
Daily: how many hours?
Weekly: how many hours?
Monthly: how many hours?
Other, explain:
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
YES
NO
YES
NO
Have you ever worn a respirator?
Do you feel you have or will have any general or specific problems wearing a respirator? If yes,
explain:
Have you felt any shortness of breath while wearing a respirator?
If yes, is this with exertion only, or at rest?
exertion
at rest
During the past 3 years, have you worn a respirator for duty other than drills?
Have you had a weight change greater than 20 lbs. since your last respirator fit test?
Have you ever had a chest injury or chest surgery?
If yes, explain:
Do you have trouble smelling odors?
If yes, explain:
Do you have a fear of tight or enclosed spaces?
If yes, have you felt claustrophobic when wearing a respirator?
Do you have a sensation of smothering when wearing a respirator?
Have you had heat exhaustion or heat stroke? If yes, when?
HEART
15. Have you had angina, a heart attack, or any other type of heart disease/conditions?
If yes, explain:
Are you under a doctor’s care?
If yes, explain:
16. Have you ever had heart surgery?
If yes, explain:
FORM 4086 (REV. 6/02)
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 16 of 17
HEART
17. Do you have or have you had high blood pressure?
Are you taking medication for your blood pressure?
Was your blood pressure normal when last checked?
When was your blood pressure last checked?
List blood pressure medication(s):
18. Do you have chest tightness when you exert yourself?
If yes, explain:
Are you under a doctor’s care?
If yes, explain:
YES
NO
SMOKING
19. Have you ever smoked?
How long?
Do you smoke now?
When did you quit?
20. Are you currently a smoker?
If so, do you smoke
cigarettes
cigars
21. How much do you currently smoke per day?
YES
NO
LUNGS
22. Have you ever had a lung disease or lung problem?
Bronchitis – when?
Emphysema – when?
Asthma – when?
Other – when?
23. Do you have a persistent cough (over 2 months of the year)?
Do you cough first thing in the morning?
Do you produce phlegm?
24. Do you have shortness of breath at night, when climbing stairs, or while dressing?
25. Does your chest ever feel wheezy or sound like it’s whistling?
26. Do you have seasonal allergies?
Do you take allergy medications?
List medication(s):
YES
NO
OTHER
27. Do you get faint or light-headed?
If yes, when?
28. Do you have a seizure disorder?
How often do you have a seizure?
Do you take medications for seizures?
List medication(s):
YES
NO
pipe
MEDICATIONS
29. List all medications (not yet listed) that you take each day:
None
I certify that the information, which I have provided, is complete and accurate. I understand that I can speak with a medical staff member
about any questions on this health history questionnaire. Contact the appropriate Medical Evaluation Coordinator for your location.
SIGNATURE OF EMPLOYEE
DATE
AIR PRODUCTS MEDICAL STAFF USE ONLY
FIT FOR RESPIRATOR USE
Yes
No
Only with the following limitations
FIT FOR HAZARDOUS MATERIAL / EMERGENCY RESPONDER
Yes
No
Only with the following limitations
SIGNATURE OF MEDICAL EVALUATION COORDINATOR
DATE
ADDRESS
TELEPHONE NUMBER
FORM 4086 (REV. 6/02)
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.
01.13.24, Rev. 0, Page 17 of 17
ATTACHMENT 7
Example of Possible Worse Case Scenario for HazMat Technicians and HazMat
Specialists
A tube trailer containing 21,000 lbs. of anhydrous hydrogen chloride is involved in a transportation
accident. The unit rolls down an embankment and is leaking. The weather is hot and humid (95 F and
95% humidity). A large fume cloud is coming from the unit.
It is necessary for personnel approaching the unit to wear SCBA and fully encapsulated acid suits.
Environmental conditions mandate no longer than 15 minutes in this PPE to prevent dehydration and heat
exhaustion. Entrance to scene is required for the following operations:
1)
2)
3)
Assessment
Repair
Construction of transfer and disposal rigs.
The control systems are located so control can be accomplished outside the cloud. The liquid phase
cannot be accessed so all disposal must be done vapor phase. Past experience has show it takes ~ 40
hours to dispose of one tube containing 3000 lbs. If all seven tubes need disposal, the operation could
last ~ 280 hours (12 days). This would require three men working 16 hours on/ 8 hours off for 12 days.
Once the men start, they would remain on site until completion (sleeping 8 hours in the truck). While on
shift they are performing heavy labor involving moving 55-gallon drums and sacks of materials. This can
be done while wearing SCBA and rain gear. The operators do not have the mask in place but must have
the unit on and ready.
The personnel must be traveling up and down the embankment carrying equipment. The area is now a
quagmire from the fire hoses being used to knockdown the fumes.
All information herein is the property of Air Products and Chemicals, Inc., and is intended for internal use only.
This document is subject to return on demand and must not be disclosed or reproduced without prior written consent.