chapter 3 u.s. army health programs and services(public law 91-596, 29 united states code 651 et...

U.S. Army Health Programs and Services

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*Lieutenant Colonel (P), U.S. Army; Director, Occupational and Environmental Health, and Director, Occupational Medicine ResidencyProgram, U.S. Army Environmental Health Agency, Edgewood Area, Aberdeen Proving Ground, Maryland 21010-5422; formerly, Occupa-tional Health Consultant to The U.S. Army Surgeon General

†Senior Occupational Health Nurse Consultant (ret), Occupational and Environmental Medicine Division, U.S. Army Environmental HygieneAgency, Aberdeen Proving Ground, Maryland 21010-5422

Chapter 3

U.S. ARMY HEALTH PROGRAMSAND SERVICES

DAVID P. DEETER, M.D., M.P.H., F.A.C.P.M.*; AND JANET M. RUFF, R.N., M.P.H.†

INTRODUCTION

LAWS, REGULATIONS, AND GUIDANCEPublic Law 79-658The Occupational Safety and Health ActFederal Employees’ Compensation ProgramRegulations and Guidance Applicable to Employee Health

ORGANIZATION OF THE ARMY’S OCCUPATIONAL HEALTH PROGRAMPreventive Medicine Service Employee Health ProgramArmy Health Clinic Employee Health ProgramOccupational Health Clinics and Nursing OfficesHealth Program Staffing

MEDICAL RECORDS MANAGEMENTOccupational Medical RecordsMedical Reports for the Employee Health Program

MEDICAL SURVEILLANCEDetermining the Need for SurveillanceDesigning Medical SurveillanceDetermining the Screening ContentUsing Medical Surveillance Results

OCCUPATIONAL HEALTHCARE SERVICESPreventive Medicine ServicesClinical Services

SUMMARY

Occupational Health: The Soldier and the Industrial Base

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INTRODUCTION

Soldiers are considered to be military employees;when they perform work that is separate from theircombat duties, they frequently encounter potentiallyhazardous exposures that are similar to civilian in-dustrial exposures. When soldiers are thought of inthis context, the military must address the potentiallyharmful effects of the work that soldiers do, and theconditions under which they work, just as these areaddressed for civilian employees in the federal gov-ernment and private-sector work force.

Employee health programs and services focus ontwo interrelated aspects: (1) to prevent or reduce nega-tive interactions between a job and an employee’shealth, and (2) to provide clinical services to employ-ees. However, differences exist between military andcivilian employees in both their eligibility for healthservices and the manner in which the services areprovided. Soldiers are eligible for health services at amedical treatment facility (MTF) for all illnesses and

injuries regardless of the cause. Department of theArmy (DA) civilians are eligible only for job-relatedhealth services and emergency and palliative treat-ment. Although the Army Medical Department(AMEDD) provides all of the healthcare to soldiers(including employee health services), the only servicesthat are available to civilian employees are those specifi-cally provided in the context of occupational health.

Before 1974, assorted health clinics, occupationalhealth sections, and nursing offices were establishedby most army installation commanders to providehealth services to civilian employees of the army.However, in 1974, the Health Services Command (HSC)was activated and all of the installation clinics, nursingoffices, and occupational health sections and programswere incorporated into the local HSC activity. Theresponsibilities for managing all the aspects of civilianemployee health were given to army Preventive Medi-cine Services within the various HSC activities.

LAWS, REGULATIONS, AND GUIDANCE

Several laws and regulations protect the health andpromote the effectiveness of all federal employees—military and civilian—including (a) Public Law 79-658, (b) the Occupational Safety and Health Act(OSHAct) of 1970, and (c) DA regulations. Technicalguidance does not carry the same weight as a law or aregulation; it is professional advice published to aidoccupational health providers and managers.

Public Law 79-658

The first law that authorized health services forfederal civilian employees was Public Law 79-658,entitled Health Promotion for Government Employees(also known as 5 United States Code 7901, 1946 asamended). This law authorized, but did not require,federal agencies to establish health-service programsto promote and maintain the physical and mentalfitness of their employees within the limits of theirappropriations. Public Law 79-658 limited employeehealth services to

• the treatment of on-the-job illnesses,• the treatment of dental conditions that require

emergency attention,• preplacement and other job-related health-

maintenance examinations,

• the referral of employees to private physiciansand dentists, and

• preventive programs related to health.

The Occupational Safety and Health Act

The Occupational Safety and Health Act of 1970(Public Law 91-596, 29 United States Code 651 et seq.)succeeded Public Law 79-658 in addressing occupa-tional health for federal employees. This law requiresthat all employers provide a safe and healthy workingenvironment for all of their employees. Although thelaw originally exempted federal employees (bothwithin and without the Department of Defense [DoD]),later provisions included them. For example, Execu-tive Order 12196 (Occupational Safety and Health Pro-grams for Federal Employees) and Title 29, Code ofFederal Regulations Part 1960, Basic Program Elementsfor Federal Employee Occupational Safety and Health Pro-grams state that (a) OSHAct applies to all federalgovernment agencies and (b) the Occupational Safetyand Health Administration (OSHA) requires federalagencies to establish an occupational safety and healthprogram. Department of Defense Instructions (DoDIs)also direct implementation of the occupational safetyand health program for military and civilian DoDemployees.


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Federal Employees’ Compensation Program

The Federal Employees’ Compensation Act waspassed in 1916; it provides compensation benefits tofederal civilian employees for disabilities caused bypersonal injury or disease that are sustained while job-related duties are being performed. The 1916 Act alsoprovides for the payment of benefits to the employee’sdependents if the work-related injury or disease causesthe death of the employee. The provisions of the Actand information concerning the administration of theworkers’ compensation program are contained in Title20, Code of Federal Regulations.1

The Office of Workers’ Compensation Programs ofthe U.S. Department of Labor is responsible for ad-ministering workers’ compensation programs for fed-eral civilian employees. However, two divisions ofthis office actually administer the program: (a) theDivision of Federal Employees’ Compensation ad-ministers the program for appropriated-fund employ-ees (that is, those employees who are primarily paidfrom the monies that Congress appropriates to run theagency); and (b) the Division of Longshoremen’s andHarbor Workers’ Compensation administers the com-pensation program for nonappropriated-fund employees(that is, employees—generally civilians—who workfor activities that create their own income by provid-ing services).

Workers’ Compensation for Appropriated-FundEmployees

The Civilian Personnel Office at military installationsis usually responsible for administering the workers’compensation program at the local level for appropri-ated-fund employees. However, commanders, su-pervisors, safety personnel, physicians, and nurses allplay a role in administering the program. The DA’smain objective for the program is to provide—aspromptly as possible—all of the benefits to which anill or injured civilian employee is entitled. The armyalso is concerned that employees who have recoveredfrom their injuries, either partially or completely,return to work. All army installations are required toestablish a light-duty program to accommodate thoseinjured employees who may not be able to work attheir regular jobs, but who may perform light-dutytasks. In addition, procedures must be established tobring long-term disabled employees back to work.2

The workers’ compensation program has otherbenefits for the appropriated-fund employee. It (a)provides for the medical care necessary for the treat-ment of job-related injuries or illnesses, (b) contains astipulation for the continuation of pay following a

traumatic injury, and (c) allows for the injured em-ployee to choose a physician.

Under the Federal Employees’ Compensation Act,an employee’s regular pay can be continued for up to45 calendar days after a traumatic injury when disabil-ity, medical treatment, or both, occur. (A traumaticinjury is defined by the Office of Workers Compensa-tion Programs as a wound or other condition of thebody that is caused by an external force, includingstress or strain.) After the entitlement to continuationof pay is exhausted, the employee may apply forcompensation if additional time is needed to recoverfrom the traumatic injury.

The Federal Employees’ Compensation Act alsoentitles an employee to choose among all licensedphysicians in private practice or physicians at a federalmedical treatment facility. Under this stipulation, theterm physicians also includes podiatrists, dentists, clini-cal psychologists, optometrists, and chiropractors;each medical officer must practice within his or herspecialty as it is defined by state law. In an effort toreduce civilian workers’ compensation claims, the armyencourages injured civilian employees to be evalu-ated initially at a federal MTF and to be treated thereif the resources are available. These governmentfacilities are staffed by active-duty medical officersand civilians, and include hospitals of the army, navy,air force, and Veterans Administration. However,when an employee chooses to be treated by a privatephysician, the staff of the Employee Health Programshould monitor the progress of treatment and per-form a follow-up examination when the employeereturns to work.

The workers’ compensation program also providesmedical care benefits. These benefits include theexaminations, treatments, hospitalizations, medica-tions, appliances, supplies, and transportation thatare necessary to obtain adequate medical care.

Workers’ Compensation for Nonappropriated-FundEmployees

The Nonappropriated Fund Instrumentalities Actof November 1958 (now known as United States Code8171-8173) provides workers’ compensation coveragefor nonappropriated-fund employees under theLongshoremen’s and Harbor Workers’ CompensationAct. Workers’ compensation benefits are provided bya self-insured workers’ compensation program man-aged by the U.S. Army Central Insurance Fund.3 Theservices that are provided to nonappropriated-fundemployees are similar to those that are provided toappropriated-fund employees under the Federal Em-ployees’ Compensation Act. However, the army MTF


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responsibilities are limited to providing initial andemergency care without charge; referral to communitymedical resources occurs if and when further medicalcare is required as determined by the physician.

Workers’ Compensation Claims Procedures

Employees and federal agencies must use specificforms and procedures to initiate claims for traumaticinjury, occupational disease, recurrence of disability,and death.4 Most of the forms include a statement ofthe purpose of the form, directions for completing andsubmitting the form, the party responsible for itspreparation, the date by which it must be submitted,and to whom it must be submitted.

Regulations and Guidance Applicable toEmployee Health

The primary Employee Health Program laws andregulations are listed in Exhibit 3-1. Other publica-tions that pertain to the program are listed in therecommended reading at the end of this chapter.

To ensure effective management of the EmployeeHealth Program, the staff must also develop andmaintain administrative documents. A good admin-istrative structure is basic to providing effective em-ployee health services and managing the program.

In addition to the laws and regulations that havealready been discussed, other army directives include(a) an installation occupational health regulation, (b)an occupational health program document, (c) stand-

ing operating procedures (SOPs), and (d) medicaldirectives for occupational health nurses.

Installation Occupational Health Regulations

The installation occupational health regulation,based on the documents in Exhibit 3-1 and publishedarmy policies, defines policy and instructions as theyapply to that particular installation.5 At a minimum,this regulation should define the extent of the occupa-tional health program, the eligibility for its services,and the responsibilities of (a) the occupational healthstaff to provide employee health services at the locallevel, (b) all installation occupational health partici-pants such as the safety and civilian personnel offic-ers, and (c) the employees who receive the services.

During the development of the regulation, the draftmust be passed through all the activities and divisionsthat have a designated occupational health responsi-bility. After the local regulation is published, it mustbe kept current through periodic reviews and up-dates. Either the occupational health physician or theoccupa-tional health nurse or both must contribute toany in-stallation directive that involves occupationalhealth, from its initial development through the staff-ing stages.

Program Document

Commanders of Medical Centers (MEDCENs) andMedical Department Activities (MEDDACs) are re-sponsible for publishing an occupational health pro-

EXHIBIT 3-1

PRIMARY EMPLOYEE HEALTH PROGRAM REGULATIONS

Department of Labor, Occupational Safety and Health AdministrationTitle 29, Code of Federal Regulations, Part 1910, Occupational Safety and Health Standards*

Department of the Army and the Health Services CommandArmy Regulation 40-5, Preventive MedicineArmy Regulation 40-3, Medical, Dental, and Veterinary CareHealth Services Command Regulation 40-30, HSC Operating Program—Preventive Medicine Program for

MEDCEN/ MEDDACHealth Services Command Regulation 10-1, Organizations and Functions Policy

Office of Personnel ManagementFederal Personnel Manual, Chapter 339, Medical Qualification DeterminationsFederal Personnel Manual, Chapter 792, Federal Employee Health and Counseling ProgramsFederal Personnel Manual, Chapter 810, Injury CompensationFederal Personnel Manual, Supplement 293-31, Basic Personnel Records and Files System

*Published annually


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gram document that identifies the preventive medi-cine services that are available.6 The document shouldinclude the program objectives, target dates for theaccomplishment of each objective, methods to achievethe objectives, and an evaluation plan. As an adden-dum to the Preventive Medicine Services general pro-gram document, good management practice dictatesthat the employee health staff develop and review theEmployee Health Program section of the documentannually. The Employee Health Program plan andobjectives must be consistent with the overall installa-tion and MTF mission, priorities, and resources.

Frequently, the manager of the Employee HealthProgram will be called upon to (a) defend the programagainst reductions in the budget, personnel, and space;(b) justify requests for more resources; and (c) assurethe commander that the Employee Health Program ishelping to accomplish the installation’s mission. Anup-to-date, meaningful program document, repre-senting both a plan for the future and a report on pastperformance, will be invaluable in these situations.The successful development and management of acontinuing Employee Health Program depends notonly on the quality of the program document but alsoon the extent to which it is followed.

Standing Operating Procedures

The basic management tools for the EmployeeHealth Program, SOPs consist of a written set ofinstructions and detailed step-by-step operationalprocedures for accomplishing an organization’s spe-cific tasks. An SOP is an internal document andincludes only the steps that employees in the immedi-ate organization perform. SOPs assist in training newemployees and serve as continuity tools in instanceswhen regular personnel are absent, enabling others tocarry on the operation. To be of value, SOPs must beused by the personnel for whom they were intendedand updated at least annually.

Medical Directives

Medical directives are the physician’s written or-ders to the occupational health nurse for administeringtreatment in the physician’s absence. Directives mustinclude the steps to follow in providing emergencycare and must list the treatments of occupational andnonoccupational illnesses and injuries. Written medi-cal directives are required to assure that emergenciesare properly handled in the absence of a physician, todirect medical care for minor incidents that do notrequire the services of a physician, and to authorizeother nursing staff activities such as changing a dressing.

The written medical directives must include in-structions for the occupational health nurse to admin-ister only noncontrolled pharmaceuticals as a one-time dose (when a nonprescription drug is thetreatment of choice). The drugs, selected from a list ofonly nonprescription drugs, are authorized by thelocal Therapeutic Agents Board. Instructions for pre-scription drugs are not included in medical directivesbecause it is not within the purview of usual occupa-tional health nursing practice to administer prescrip-tion drugs in the absence of a physician.

Medical directives should be consistent with theanticipated requirements for employee health ser-vices and the capabilities of the nursing staff. Thus,the physician should coordinate with the occupa-tional health nurse manager and supervisor to pre-pare the directives. The physician must sign and datethese directives.5 Occupational health nurses whoparticipate in the preparation of medical directivesshould cosign them.

Clinical guidelines require periodic review andrevision of the directives both as medical knowledgeincreases and as other changes occur at the installa-tion. At a minimum, the occupational health physi-cian and nurse must review the medical directivesannually, and indicate this review with their signa-tures and the review date.5

ORGANIZATION OF THE ARMY’S OCCUPATIONAL HEALTH PROGRAM

The army operates more than 130 individual Em-ployee Health Programs. These programs’ missionsand structures vary from installation to installationbecause each installation has specific employee-healthneeds. There are, however, a few basic designs forthese programs.

The position of the Employee Health Program withinan organization depends on whether it is collocatedwith a MEDDAC or MEDCEN, both of which includea hospital and a Preventive Medicine service, or with

an Army Health Clinic (AHC), which is located at aninstallation without a hospital and has no PreventiveMedicine service. HSC Regulation 10-1, Organizationand Functions Policy, prescribes the organization andthe functions of AMEDD activities under the com-mand Headquarters, U.S. Army Health Services Com-mand; HSC Regulation 40-5, Ambulatory Patient Care,further defines the operations of the AHCs and oc-cupational health clinics. Compliance with these regula-tions allows the Employee Health Program to operate


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within either the Preventive Medicine Service or thehealth clinic system.

Preventive Medicine Service Employee HealthProgram

In those installations that have an army hospital,the occupational health section of the Preventive Medi-cine Service conducts the Employee Health Program(Figure 3-1). Often the occupational health section hasno clinical capabilities, but it manages all the admin-istrative aspects of occupational health for both civil-ian and military employees who work at the installa-tion. The staff of the collocated MEDDAC or MEDCENperforms all of the preventive and clinical services forpatients, including treatment and examinations. How-ever, at installations where a mobile occupationalhealth vehicle (MOHV) is assigned, the staff of theoccupational health section uses the vehicle to pro-vide preventive services at the worksite (Figure 3-2).

The staff of an occupational health section usuallyconsists of one to three civilian occupational healthnurses, a clerk, and often an industrial hygienist,depending on both the size of the population that is tobe served and the health services that are required.The occupational health nurse serves as the EmployeeHealth Program manager, except when a full-timephysician is assigned to the section.

Physician’s assistants with 2 years of postgraduatetraining in occupational health are assigned to severalof the larger U.S. Army Forces Command (FORSCOM)installations, where they serve as program managersfor those employee health services that are providedto soldiers.

In the absence of a full-time physician, the chief ofthe Preventive Medicine Service (if he or she is aphysician), or a physician who is assigned to theMEDDAC or MEDCEN in another capacity, may pro-vide occupational medicine support. This type ofsupport is most commonly found at FORSCOM and

Fig. 3-1. The typical organizational structure for occupational health services on a larger army Training and DoctrineCommand (TRADOC) or army Forces Command (FORSCOM) installation with a post U.S. Army hospital.

Specialized Laboratory Tests

Division, Primary Care anCommunity Medicine

Preventive Medicine Servic

Regional MEDCEN or MEDDAC

BENEFICIARIES

Mission

Staffing

Clinical Guidanc

Technical Guidance Command and Control

•

•

•

HEALTH SERVICES COMMAND

Occupational Healt

PhysicianTwo or More NursesAdministrative StaffSupport Staff

Civilian Employee

OCCUPATIONALHEALTH

SECTION


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Fig. 3-2. The mobile occupational health vehicle (MOHV). The staff of the occupational health section use the MOHVto provide preventive health services at the worksite. Often power stations are set up at different locations so thevehicle can be moved from site to site according to a prearranged schedule. The U.S. Army deployed 11 MOHVs toSaudi Arabia during Operation Desert Storm.

U.S. Army Training and Doctrine Command(TRADOC) installations.

Army Health Clinic Employee Health Program

The Employee Health Program is a part of the AHCat U.S. Army Materiel Command installations. TheAHC is organizationally located in the Department ofPrimary Care and Community Medicine of the re-gional MEDDAC or MEDCEN (Figure 3-3). The staffof the AHC usually includes one or two physicians(either military or civilian), several civilian nurses, andother administrative and support personnel. A phy-sician is the director and possibly also the commanderof the clinic. An AHC usually has general radiologyand laboratory capabilities. With these staff and tools,the AHC’s mission is to deliver both the civilianEmployee Health Program and outpatient healthcareservices to active-duty soldiers, their dependents, andretirees. The regional MEDDAC or MEDCEN alsoprovides support such as specialized laboratory testsor audiology consultation when it is needed.

Although providing employee health services tocivilian employees who are assigned to the installa-tion can be a major part of the clinic’s mission, manag-ing the civilian Employee Health Program is often anadditional, secondary responsibility. The EmployeeHealth Program is usually integrated into the AHC’soverall services, and the entire staff provides theemployee health services. Often, one of the civilianphysicians and several of the civilian nurses will be

designated with the prefix occupational health on theTable of Distribution and Allowances, the officialstaffing document that identifies all positions, includ-ing specific clinic positions.

Each Employee Health Program should have a desig-nated program manager; this is usually the senioroccupational health nurse. In clinics where there isno actual position for an occupational health physi-cian, one of the clinic physicians is assigned the re-sponsibility of providing occupational medical con-sultation to the Employee Health Program. Otherstaff members may be assigned particular occupa-tional health responsibilities, such as administeringthe hearing conservation program. The Departmentof Primary Care and Community Medicine managesthe clinical aspects for most AHCs, but the supportingMEDDAC or MEDCEN Preventive Medicine Serviceprovides technical guidance and support for occupa-tional health.

Occupational Health Clinics and Nursing Offices

Occupational health clinics are medical treatmentactivities whose primary missions are to provide oc-cupational health services to military and civilianemployees who work at the installation, and sick-callservices to service members located in the immediatearea (Figure 3-4). A physician heads this separatelyestablished operation, with a staff including civiliannurses and support personnel. The army has ninedesignated occupational health clinics. They are lo-


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Fig. 3-3. The typical organizational structure for a U.S. Army health clinic at an installation without a post U.S. Armyhospital, where primary care is the predominant healthcare mission.

BENEFICIARIESActive-Duty Soldie

DependentsRetirees

Civilian Employees

Missions

StaffingOne to Two PhysiciansTwo or More NursesAdministrative StaffSupport Staff

Outpatient Primary CaOccupational Healt

Clinical GuidanceCommand and Control

Technical Guidanc •

•

• Specialized Laboratory Tests




Radiological Services

Laboratory ServicesARMY HEALTH

CLINIC

Division, Primary Care aCommunity Medicine

cated at small installations such as the U.S. ArmyNatick Research Development and Engineering Cen-ter, where most workers are civilian and few militarymedical beneficiaries are in the area.

Occupational health nursing offices are similar to occu-pational health clinics but they lack a full-time physi-cian (Figure 3-5).7 These occupational health nursingoffices are usually organizationally a part of the Pre-ventive Medicine Service; most are located in leasedfederal office buildings in and around Washington, D.C.

Health Program Staffing

According to regulations of the army and the Officeof Personnel Management, Employee Health Programsmust be adequately staffed.5,8 The size and experienceof the staff of an occupational health section (or Em-ployee Health Program, occupational health clinic,occupational health nursing office) depend on thepopulation to be served, type of installation, range of

employee health services provided, and availabilityof the resources.

All Employee Health Programs require at least onefull-time civilian occupational health nurse, either afull-time or part-time physician, and clerical support.DA Pamphlet 570-557 provides guidance for deter-mining staff requirements.9 The pamphlet defines thecivilian or military staffing levels that the army rec-ommends for the Employee Health Program, regard-less of the program’s administrative structure.

Army Regulation (AR) 611-101 describes the com-missioned officer’s qualifications according to the spe-cialty skill identifier (that is, a two-component numeric-alpha description that identifies the skills needed for aparticular job).10 For example, an active-duty occupa-tional medicine officer is a 60-D. The Office of PersonnelManagement Handbook X-118 describes the qualifica-tions for each civilian General Schedule (GS) job series.11

The Civilian Personnel Office provides guidanceand establishes local procedures for all civilian per-


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BENEFICIARIESMilitary and

CivilianEmployees

Mission

Staffing

One to Two PhysiciansTwo or More NursesSupport StaffAdministrative Staff

OCCUPATIONALHEALTHCLINIC

•

•

Radiological Services

Laboratory Services


Occupational Healt


• Specialized Laboratory Testi


Clinical Guidanc


Division, Primary Care anCommunity Medicine

Fig. 3-4. The typical organizational structure for a U.S. Army occupational health clinic at an installation without a postU.S. Army hospital, where occupational health is the predominant healthcare mission.

sonnel administrative requirements. For example, ajob description must accurately specify the functionsof each position. Both the Civilian Personnel Officeand the job supervisor are responsible for preparingeach civilian employee’s job description. The CivilianPersonnel Office defines the technical aspects of thejob description and the supervisor defines the jobfunctions and supervisory controls. In addition, per-formance standards, which are based on the dutiesdelineated in the job description, are required for allcivilian staff members. The supervisor defines theacceptable level of performance for major duties, andthese standards are used as a basis for evaluating anemployee’s job performance.

Once professional and technical personnel are as-signed to the occupational health area, they are re-sponsible for maintaining their own current licensureand certification according to legal and professionalrequirements. Each individual is responsible for hisor her own continuing education.

The Occupational Health Physician

Either a military or civilian physician may fill theposition of occupational health physician; however,their qualifications are different. While the MEDDACor MEDCEN credentialing committee must approveboth military and civilian occupational health physi-cians for clinical privileges as an occupational healthphysician,12 civilian physicians must also meet theOffice of Personnel Management’s minimum qualifi-cations for the position. In addition, training or priorexperience in the field of occupational health is desir-able for occupational health physicians.

Whether a military officer or a civilian, the occupa-tional health physician can be assigned as a part-timeor full-time member of the Employee Health Programstaff. Usually a military physician is assigned part-time occupational health duties. (This arrangement isusually found at FORSCOM and TRADOC installa-tions.) This part-time participation is seldom adequate


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Fig. 3-5. The organizational structure of U.S. Army occupational health nursing offices in the Washington, D.C., metropoli-tan area.

BENEFICIARIESMilitary and

CivilianEmployees

Staffing

•

•


•

Occupational Healt

Clinical Guidanc


Specialized Laboratory Testi

Walter Reed AMC

OCCUPATIONALHEALTH

NURSING OFFICE

Preventive Medicine Service Civilian Employees Health Service

Division of Primary Care and Community Medicine

Mission

One Civilian Nurse

because providing occupational medicine support forthe Employee Health Program is added to thephysician’s primary assignment as a medical officer atthe MEDDAC or MEDCEN.

The Occupational Health Physician’s Assistant

The MEDDAC or MEDCEN credentialing commit-tee must approve the military or civilian occupa-tional health physician’s assistant for clinical privi-leges.12,13 Once physician’s assistants have been ap-proved to practice, they must be supervised by aphysician.12

In recent years the army has provided additionaleducation—a master’s degree in occupational health—to selected military physician’s assistants. The originalpurpose of training physician’s assistants in occupa-tional health in the army was to provide health servicesat the unit level to ensure soldiers’ combat readiness.The role of the military occupational health physician’sassistant has yet to be clearly defined; however,physician’s assistants have functioned in various ca-

pacities (for example, as managers of the Occupa-tional Health Program for soldiers or, infrequently, asmanagers of the overall Occupational Health Pro-gram for civilians and military personnel) when as-signed to the MEDDAC at FORSCOM installations.

The Occupational Health Nurse

Occupational health nurses are civilian registerednurses who meet the minimum qualifications as man-dated by the Office of Personnel Management.MEDDAC or MEDCEN clinical privileges are notrequired for occupational health nurses who practicewithin the usual limits of occupational health nursing.In addition to the basic nursing preparation, the nurseshould have specialized training such as formal aca-demic programs or short courses in occupationalhealth. These educational programs should empha-size management principles; industrial toxicology;the cause, prevention, control, and treatment of occu-pational diseases; the principles of industrial hygieneand epidemiology; the concepts and practices of job-


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related medical surveillance; and the legal and regu-latory aspects of occupational health.

Ancillary Staff

The organization of the occupational health sectiondetermines whether ancillary personnel (such as li-censed practical nurses, nursing assistants, medical

technicians, occupational health technicians, labora-tory technicians, and X-ray technicians) need to beassigned. MEDDAC or MEDCEN optometric andaudiometric technicians may also provide significantsupport to the program. Depending on the technician’slevel of education, he or she could manage selectedelements of the occupational health program such ashearing conservation.

MEDICAL RECORDS MANAGEMENT

Medical records and reports include (a) occupa-tional medical records (cumulative individual medi-cal records), (b) workers’ compensation records (medi-cal), and (c) administrative records and reports. Theoccupational medical record (civilian employee medi-cal records and the military outpatient treatmentrecords are types of cumulative individual medicalrecords) and administrative reports are required bythe Employee Health Program

An occupational medical record is the chronologi-cal, cumulative record of information about the devel-oping health status of an employee with respect to hisor her employment. Occupational medical recordsmust contain personal and occupational health histo-ries, employee exposure records, and the healthcareprofessional’s written opinions and evaluations dur-ing the course of employment-related examinations,diagnoses, and treatments. In the military outpatienttreatment record, the occupational health record con-sists of entries that are related to the soldier’s work.

Occupational Medical Records

Civilian employee medical records and outpatienttreatment records (for military personnel) serve as theoccupational medical record. The purpose of any med-ical record is to document a complete medical historyof the patient and his or her care, medicolegal supportfor the therapy that was given, and a basis for researchand education. In instances when a civilian employeehas dual status—such as a retired military member orthe dependent of a retired or active-duty militarymember—that employee will also have both a civilianemployee medical record and an outpatient treatmentrecord. Each record will be marked or coded clearly toindicate this dual status and to facilitate the identifica-tion and reporting of job-related injuries and diseases.

The MTF commander is the official custodian of themedical records at the facility, but the chief of thepatient administration division acts on behalf of thecommander in matters that involve medical records.Both the civilian employee medical records and the

outpatient treatment records should be maintained,by personnel trained in record keeping, in an MTFarea designated for medical records.

The Federal Personnel Manual Supplement 293-31,Basic Personnel Records and Files System, is the majorregulation that pertains to civilian employee medicalrecords; AR 40-66 applies to outpatient treatmentrecords; entries into all occupational medical recordsare made in accordance with AR 40-66.14 This regula-tion contains guidance on recording injuries and in-cludes a requirement to identify occupational injuriesor illnesses as occupational in the medical record.

The Report of Medical History (SF 93) is used toobtain a health history from all civilian employees andto initiate a medical record on employment. (Excep-tions can be made for transient nonappropriated-fundemployees such as food-handlers.) Once the medicalrecord is initiated with the SF 93, it is to be kept in theterminal digit series folder, Alphabetical and TerminalDigit File for Treatment Record (DA Form 3444), or in theEmployee Medical Folder (SF 66-D). When an employeeeither transfers to another federal agency or is sepa-rated from federal service, the civilian employee medi-cal record is transferred or retired in the SF 66-D. If thecivilian employee medical record has been maintainedin a DA Form 3444 during the individual’s employ-ment, the personnel responsible for maintaining thecivilian employee medical record must ensure that asigned Privacy Act Statement-Health Care Records (DoDForm 2005) is transferred or retired with the record.

In general, only standard forms (that is, those formsthat are authorized by HSC, DA, and DoD) are used inmedical records. The MTF commander must approveany locally-developed form or overprint before it isplaced in the medical record. In addition to standardforms, a copy of the Office of Workers’ Compensationforms related to medical treatment must be main-tained in the medical record.15 These forms include

• Federal Employee’s Notice of Traumatic In-jury and Claim for Continuation of Pay/Com-pensation (CA-1),


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• Federal Employee’s Notice of OccupationalDisease and Claim for Compensation (CA-2),and

• Request for Examination and/or Treatment(CA-16).

When a civilian employee separates from federalservice or transfers to another federal agency, thecivilian employee medical record is usually forwardedto the Civilian Personnel Office in the SF 66-D. TheCivilian Personnel Office retires the record to theNational Personnel Records Center when an employeeseparates from federal service, and forwards it to thegaining agency when an employee transfers.

Transferring and maintaining job-related X-rayfilms require special procedures. If it is 81⁄2 x 11 in. orsmaller, the film is placed in the medical folder (SF 66-D) and retired or forwarded as part of the medicalrecord. However, if the job-related X-ray film is largerthan 81⁄2 x 11 in. (such as a roentgenogram of a patient’schest and torso), it must be maintained separatelyfrom the SF 66-D. When an employee separates fromfederal service, the large films are maintained in theiroriginal state at the last employing agency for 30 yearsbeyond the termination of employment. The medicalrecord must also contain a notation on the radiologist’sfindings, the location of the radiograph, and how itcan be obtained. If the employee is transferring toanother federal agency, the large films are simplyforwarded to the gaining agency.15,16

Like any other medical record, the civilian em-ployee medical records must be maintained in strictconfidence. However, OSHA regulations allow theemployee, his or her representative as designated inwriting, and OSHA representatives (compliance of-ficers and National Institute for Occupational Safetyand Health [NIOSH] personnel) to examine or copymedical records or medical information that bearsdirectly on the employee’s exposure to toxic materialsand harmful physical agents such as radiation andnoise.16,17 This access is strictly limited and does notinclude access to any health information that is unre-lated to exposure.

Medical Reports for the Employee Health Program

The MTF commander is responsible for submittingseveral recurrent reports that require occupationalhealth data. The chief of the patient administrationdivision is responsible for establishing procedures forretrieving data for all required reports, and mustcoordinate with the chief of the Employee HealthProgram to identify and ensure that all occupational

health reporting requirements are met. While the staffof the Employee Health Program may or may notactually compile these periodic reports, they shouldbe aware of the data that are required and the purposefor their collection. The primary MTF reports thatrequire occupational health data include the ArmyOccupational Health Report (DA Form 3076); the Medi-cal Summary Report (MSR), RCS (Requirement ControlSymbol): MED-302; the Management Indicators for Oc-cupational Health (MIOH) Feeder Report (RCS SAOSA-220); and the Command health report. Two addi-tional reports to which Employee Health Programpersonnel may contribute include the Special Tele-graphic Reports [RCS MED-16(R4)] and the Log of Occu-pational Injuries and Illnesses.

The installation, MEDDAC personnel, and higherheadquarters (HSC and the U.S. Army's Office of TheSurgeon General [OTSG], and the installation’s majorcommand) review and evaluate the Employee HealthProgram using the data in DA Form 3076, which theEmployee Health Program staff must prepare andsubmit biannually.6 DA Form 3076 contains informa-tion about Employee Health Program staffing, thecivilian and military population at risk for potentialhealth hazards in the work environment, and thenumber and types of occupational health services thatthe Employee Health Program provides. DA Form3075 is used to collect these data. Instructions forcompleting both DA Forms 3075 and 3076 are on thereverse sides of the forms.

The MED 302 Report is one of the components ofthe DA medical information system that the MTF,intermediate headquarters (such as MEDDACs orMEDCENs), The U.S. Army Surgeon General, andother government agencies use for evaluating budgetrequests, planning programs, controlling manage-ment, analyzing manpower requirements, makingauthorizations, and planning facilities. Each armyMTF must submit the MED 302 Report every month toprovide a timely and accurate medical summary ofthe services that the entire MTF provides. A defi-ciency of this report is that it does not fully recognizethe workload of the preventive medicine services, butconcentrates only on the services that are provided toill patients. The chief of the patient administrationdivision usually requests specific data from the Em-ployee Health Program staff to formulate this report.

Local program managers and higher headquartersuse the specific data in the MIOH Feeder Report whenthey analyze and review occupational health in thearmy. The report reflects the numbers of occupationalhealth staff, the population at risk, and the programevaluations that have been performed. Data concern-


73

ing the Industrial Hygiene and Hearing Conservationprograms are provided, in addition to data regardingthe Employee Health Program. All MEDCENs andMEDDACs that provide health services for active-duty soldiers and civilian employees must preparean MIOH Feeder Report for their health-service areabiannually.18

Each month, every installation’s Medical Author-ity (that is, the senior physician assigned to theMEDDAC at the installation) is required to providethe installation commander with the Command healthreport.5 Although there is no specific format requiredfor this report, it summarizes the conglomerate healthstatus of the command and the people who comprisethe command. The Command health report provides

• information regarding health conditions withinthe command;

• recommendations for, or descriptions of, ac-tions taken to improve health conditions;

• advice to higher headquarters regarding thesupport needed to implement the recom-mended actions; and

• information regarding outstanding accom-plishments, new developments, and trends.

The Special Telegraphic Reports [RCS MED-16(R4)]are unique reports that provide epidemiological dataand the results of epidemiological investigations onselected health conditions, disease outbreaks, deaths,and attempted suicides. These reports include theSpecial Telegraphic Report of Selected Condition, the Spe-cial Telegraphic Report of Reportable Outbreak, and the

Special Telegraphic Report of Reportable Death.19 Preven-tive medicine personnel have used the MED-16 reportextensively to document outbreaks of infectious dis-ease. However, it is equally important to notify higherheadquarters of outbreaks of injury or disease, orunusual occupation-related health events, such as oneor more cases of overexposure to ionizing or nonion-izing radiation, or if two or more persons have beenremoved from their jobs as a result of abnormal job-related medical surveillance tests. The submission ofany of these reports requires liaison among Preven-tive Medicine staff (including the Employee HealthProgram staff), the patient administration division,and other medical staff.

All federal agencies are required to collectoccupational injury and illness data and to recordthese in the OSHA Log of Federal Occupational Inju-ries and Illnesses.20,21 Although the installation’s safetyofficer usually has the primary responsibility for col-lecting data and maintaining the log, coordinationwith the occupational health staff and the local Fed-eral Employees’ Compensation Act Program admin-istrator is essential to ensure that the data are com-plete. The safety office should report all of the followingin the log:

• occupational illness,• job-related injuries that resulted in death or

disability,• job-related injuries that caused employees to

lose time at work (other than the day on whichthe injuries occurred), and

• job-related injuries that required medical care.

MEDICAL SURVEILLANCE

The two principal missions of occupational health inthe army are not distinctly separate, but they are verydifferent: (1) reducing negative job-health interactions ispreventive and applies to the general population ofworkers, as well as to the individual worker; and (2)providing healthcare services is clinical and applies tothe individual employee as a patient. These elementsof the Employee Health Program can be discussedseparately. A basic tool for the preventive aspects ofoccupational health is medical surveillance. Job-relatedmedical surveillance in the field of occupational healthconsists of systematically and periodically collectingand analyzing health data on groups of employees forthe purpose of early detection of the increased risk, orthe actual presence, of negative job-health interac-tions. Medical surveillance can be used to achieve

• primary prevention, which is oriented to pre-venting the risk;

• secondary prevention, which is oriented toreducing or preventing the exposure; and

• tertiary prevention, which is oriented to re-ducing or preventing long-term impact of thehealth effect.

When using medical surveillance as a primary orsecondary prevention tool, we view the individual asan employee. When we use medical surveillance fortertiary prevention, we view the individual both as anemployee and as a patient. The surveillance resultsare used for the diagnosis and treatment of the clinicalcondition and to indicate that a change (for example,light duty) is needed in the workplace.


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Primary prevention is defined as

a means of preventing the occurrence of illness orinjury; for example, by immunization against infec-tious disease and by using safety equipment to pro-tect workers in hazardous occupations.22

It seeks to reduce or eliminate risk through interven-tion before exposure to that risk. Thus, when the risksthat are associated with a particular job and the healthcharacteristics of the employee that place the em-ployee at increased susceptibility to those risks can bedetermined, then medical surveillance can be used toidentify those employees who will be at the greatestrisk, and prevention can be directed at these employ-ees. Of course, prevention cannot be effective until thedata from surveillance are used to enforce a change,thereby reducing the occupational risk.

Primary prevention seeks to reduce or eliminate therisk by avoiding exposure. For example, it can be assimple as performing glucose-6-phosphate dehydro-genase (G6PD) tests on all who might be exposed tonitrate-containing compounds, such as the explosivesRDX and M6 (a propellant used for artillery). Expo-sure to nitrates can cause methemoglobin to form;the G6PD enzyme converts methemoglobin back tohemoglobin. Individuals with the genetically deter-mined G6PD-enzyme deficiency (such as those of Medi-terranean heritage) may be unable to make the con-version rapidly enough to prevent signs of methemo-globinemia. Therefore, a one-time preplacement sur-veillance for G6PD levels can prevent the worker frombeing exposed, and thus avert the risk of methemoglo-binemia by taking preventive action based on thefindings.

Secondary prevention includes both detecting deleteri-ous health effects and intervening before an illnessbecomes clinically apparent, with the goal of retard-ing, halting, or reversing the progress of the illness.Medical surveillance can be used in secondary pre-vention to detect job-related health effects prior to theonset of clinical disease. Surveillance becomes a sec-ondary prevention tool only when the data collectedare used to guide interventions that are effective.Other than in hearing conservation, there have beenno systematic efforts to conduct medical surveillancefor soldiers, with the exception of the routine physicalexaminations required to remain on active duty.

During the demilitarization of the chemical agentBZ (one of the incapacitating chemical warfare agents),the workers were enrolled in a very strict medicalsurveillance program to assure that early signs andsymptoms of exposure to BZ would be detected. Im-portant to this program was the measurement of the

size of the workers’ pupils before and after they en-tered the chamber. BZ exposure causes mydriasis;while mydriasis is not in itself incapacitating, it isone of the most sensitive indicators of exposure. Notuntil a worker was actually seen with mydriasis oneafternoon was it learned that the procedures used bythe workers to decontaminate themselves after theirworkshifts might be inadequate. Not realizing thather hands could have been contaminated, the workerpassed her hands over her hair and over her eyes asshe showered, transferring the BZ directly. The amountof BZ was so small that only direct contact with hereyes could have caused her pupils to enlarge. There-fore, showering procedures were changed; the work-ers were instructed to assume that their hands werepotentially contaminated, and to wash them first. Inthis instance, medical surveillance was an effectivesecondary prevention tool; it did not prevent expo-sure, but it detected the physiological effect of expo-sure before an important clinical event occurred.

Tertiary prevention includes both the detection andtreatment of an illness, or the rehabilitation of aninjured or ill person, sufficiently early in the course todecrease the long-term impact that the illness or in-jury may have on that individual. Medical surveil-lance is a tertiary prevention tool when it is used to (a)document that the job has already affected anemployee’s health or (b) demonstrate that an em-ployee is not fit for duty after an event has occurred.

The following example demonstrates medical sur-veillance in its primary, secondary, and tertiary pre-vention roles. Carpal tunnel syndrome (CTS) is acondition associated with certain repetitive-motionoccupations such as keyboarding. A medical surveil-lance program for keyboard operators could includedisqualification of any individual who reports previ-ously existing CTS on preplacement history. For thisjob, exclusion serves as primary prevention. Theprogram would also include limited annual historiesfor all keyboard operators to detect the early symp-toms of CTS. Any positive findings (for example,subclinical tingling in the fingers) would be followedup by actions to determine workplace practices and torule out clinical disease. This medical surveillanceprogram serves as secondary prevention when it hasdetected subclinical findings and the Employee HealthProgram staff has taken action to prevent furtherexposure. The same program serves as tertiary pre-vention when a worker presents with clinical signs ofCTS and the actions taken in the workplace are doneto prevent further exacerbation of the condition

Medical surveillance is prospective and ongoing innature. Effective, efficient, and economical job-relatedmedical surveillance must encompass (a) the design of


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the surveillance program, (b) the performance of medi-cal screening, and (c) the use of the surveillance data.The occupational healthcare professional must fullyunderstand that medical surveillance and medicalscreening are two different concepts (Table 3-1). Medi-cal screening is the one-time determination of thepresence or absence of a health characteristic in anindividual or a group at risk. Medical screening iscross-sectional and periodic. Only rarely have one-time abnormal screenings demonstrated job–healthinteraction.

Lead exposure and its medical indicators illustratethe concepts of medical screening and medical surveil-lance. Blood-level determination is an excellent screen-ing tool for lead exposure because an elevated value oflead in the blood is related both to exposure and tolead’s biological effects. There are two action levelsfor lead. The first is the environmental exposure(currently, 30 µg/m3 as a time-weighted average),which determines when blood-lead screening mustbe initiated. The second is a blood-lead screeninglevel of 60 µg/dL, which requires removal from thelead exposure and more frequent screening until theindividual’s blood lead level drops below 40 µg/dL.

Clearly, screening for lead is effective in situationswhere excessive exposure to lead, and elevated bloodlevels of lead, occur. One-time, normal blood levels oflead are of little use. However, if screening is con-ducted over time (for example, 5 years), even thoughmeasured workplace levels of lead do not exceed theaction level, slowly rising normal levels can be de-tected. Steps can then be taken to control lead expo-sure before any individual worker is adversely af-fected. Careful screening together with directed actionsconstitute effective medical surveillance. Therefore,determining a blood level of lead is medical screening,whereas comparing blood lead levels over time,whether the results are normal or abnormal, is medi-cal surveillance.

Determining the Need for Surveillance

Designing an effective surveillance program andtailoring it to a given group of workers begins withdetermining (a) the reason for the surveillance and (b)the health characteristics that should be monitored.For these purposes, all employees can be divided intothree basic groups.

Group 1

The first group of employees perform jobs thatrequire minimal physical exertion and have little po-tential for exposure to job-related hazards. Medical

TABLE 3-1

MEDICAL SCREENING VERSUS MEDICALSURVEILLANCE

Characteristics

Screening Surveillance

Cross-sectional Prospective

Singular Longitudinal

Focuses on absolute values Focuses on trends(normal or abnormal)

surveillance for these employees is limited to periodicscreening to ensure that the workplace remains safeand the employees remain healthy.

Group 2

The second group of employees are those whosehealth or fitness status must be sufficient for them to beable to (a) perform their work safely and effectively, or(b) wear the personal protective equipment (PPE) re-quired at a worksite. For example, a driver should nothave any condition that could incapacitate him whilehe transports hazardous cargo. Thus, medical stan-dards for this job might include the absence of insulin-dependent diabetes mellitus, and a medical surveil-lance program would screen the driver for diabetes.(Discrimination against the medically handicapped isnot at issue here, if it has been documented that themedical condition will indeed compromise the job.)

The key to designing medical surveillance for theseemployees is to maintain clearly defined medical stan-dards. In the army, the staffs of Employee HealthPrograms do not have the authority to publish medi-cal standards, especially if employees must meet thesestandards if they are to retain their jobs. The soleauthority for medical standards belongs to the Officeof Personnel Management through the Civilian Per-sonnel Office. However, physicians should workclosely with personnel officers to develop medicalstandards when appropriate.

Performance-related medical standards that addressrequired capabilities are preferred to specification-re-lated medical standards, which require documenta-tion of the absence of specific results of screening tests.For example, a medical surveillance program shouldbe designed to ensure that employees who are re-quired to wear respiratory protective equipment arephysically capable of doing so. Disqualifying factorsfor wearing a respirator safely could include wearing


76

a beard (which would compromise the seal) and ab-normal or borderline pulmonary function.

An appropriate performance-related medical stan-dard could state that any employee required to weara respirator (a) not wear a beard and (b) have noevidence of compromised pulmonary function. Inthis case, the occupational health physician mightdecide that he or she will determine the presence orabsence of compromised pulmonary function, espe-cially in a younger population, merely by talking toand observing the employee periodically.

On the other hand, a specification-related medicalstandard could indicate that pulmonary functiontests must be performed annually, and that an em-ployee with an FEV1 (forced expiratory volume in 1sec) lower than 70% of that expected for the employee’sage group would be removed from the job. Thisspecification-related medical standard requiresunnecessary testing and also raises insurmountablequality assurance, medicolegal, and ethical difficul-ties. Fortunately, few published medical fitness stan-dards exist. The army’s Employee Health Programstaffs have the opportunity and the responsibility towork closely with management in developing localmedical fitness standards that are tailored to indi-vidual installations.

Group 3

This group of employees works with potentialchemical, physical, or biological hazards and requiremed-ical surveillance for the following reasons:

• to meet requirements where workplace expo-sures exceed one of the federal exposure stan-dards,

• to detect exposure-related health effects early,• to monitor the effectiveness of the controls,

and• to monitor the extent of the exposure.

Several acceptable means exist for tailoring job-related medical surveillance for this group of employ-ees. Medical surveillance can be based on job titles,worksites, or documented exposures and individualsusceptibility.

Designing Medical Surveillance

A medical surveillance program that is based solelyon the assumption that exposure has occurred is un-likely to be cost effective. Numerous factors contrib-ute to determining the need for and content of medicalsurveillance:

• The assumption that a worker might havebeen exposed does not mean that a biologi-cally significant dose will also have been re-ceived.

• The assumption that a biologically significantdose has been received does not necessarilymean that the dose will have been sufficient tocause a negative health effect.

• Likewise, the assumption that a negative healtheffect has occurred does not mean that anappropriate screening test also exists.

The level of exposure sufficient to trigger concernfor a group of employees is sometimes difficult todetermine. However, if an obviously uncontrolledexposure is occurring, preventive medicine dictatesthat action be taken to alleviate the exposure withoutscreening for health effects. Where uncontrolled ex-posure has not been documented, the probability thathealth effects can be demonstrated through surveil-lance is very low. Basing the need for surveillance onthe assumption that any exposure will cause negativehealth effects is neither cost effective nor sound prac-tice of occupational medicine.

Other factors further complicate surveillance de-sign. We cannot assume that all subjects in a givenpopulation will be exposed identically; also, we can-not assume that they will respond to exposure identi-cally. For example, in an army ammunition plant, twoworkers standing side by side at an assembly line maybe exposed to completely different levels of propellantfor so simple a reason as a difference in the air flow.Even if they were exposed identically, the two mightnot demonstrate the same toxic effects. Nitroglycerinunintentionally inhaled or ingested in the workplacehas exactly the same biological effect, vasodilation,as nitroglycerin taken as a prescribed medication.One worker might be very susceptible, due to hiscardiovascular status, while a coworker could be com-pletely unaffected.

Once an exposure justifies medical surveillance,other assumptions must be made concerning the ef-fects on health. First, most toxic substances affectspecific organ systems in specific ways. Often thetoxicity of the substance depends on the route ofexposure, and health effects vary with the level andthe duration of exposure. Standard toxicology text-books usually list all the effects on health that areassociated with a given poison. If the staff of theEmployee Health Program designs a screening pro-gram to demonstrate the absence of every toxic effecta particular agent might cause, the staff will, in effect,be trying to prove a negative. Such a program will beneither cost effective nor useful.


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Instead, the occupational health physician mustuse professional judgment to determine the organsmost likely to be affected if a negative job-healthinteraction has occurred. The OTSG has acceptedcriteria for determining the most likely sentinel toxiceffects, including

• the health effect on which the OSHA permis-sible exposure limit (PEL) or the AmericanConference of Governmental Industrial Hy-gienist (ACGIH) Threshold Limit Value (TLV)was originally based,

• any health effect demonstrated to occur afterexposures to airborne levels up to twice thePEL or the TLV, and

• any health effect in animals, if the exposurewas up to twice the PEL or TLV, and if otherrelated chemicals are known to cause similarhealth effects in humans.

Some employees may require job-related medicalsurveillance to meet minimum medical standards, asin the case of the second group of employees de-scribed above, and due to potentially hazardous ex-posures, as in the case of the third group. Although itmakes good sense to conduct all required surveillanceconcurrently, the occupational health practitioner mustassure that the principles outlined for both groups ofemployees are applied.

Determining the Screening Content

After the need for medical surveillance has beendetermined, the content of the surveillance must bedesigned.

Medical Surveillance Screening Tools

Four medical screening tools are available: (1) theinterim history, (2) a limited physical examination, (3)diagnostic laboratory screening, and (4) biologicalmonitoring. The effectiveness of these tools is mea-sured by their sensitivity, specificity, cost, acceptabil-ity, easeof use, accuracy, and reproducibility (Table 3-2). Fewscreening tools meet all criteria for widespread use.

Figure 3-6 provides a visual presentation of therelationships among sensitivity, specificity, and posi-tive predictive value. Sensitivity is the percentage ofpositive test results in a population that has the char-acteristic being tested (true positives). Specificity is thepercentage of negative test results in a population thatdoes not have the characteristic being tested (truenegatives). Positive predictive value depends on thespecificity of the test and the prevalence of the condi-tion in the population. Quite simply, positive predic-tive value is the percentage of true positives among allpositives. However, in the case of job-related medicalsurveillance, positive predictive value and true posi-tives must also take into account the specific etiologyof the specific effect (that is, the job-relatedness). Apatient’s liver-function test may be abnormal, butwhen considering the patient as an employee, thisabnor-mality is relevant to occupational health only ifthe abnormality is caused by a job-related exposure.

To expand further on this example, liver-functiontests can be demonstrated to have very low positivepredictive value for job-related medical surveillance.Assume that a worker population has a 5% prevalenceof job-related liver disease, and that liver-functiontests have 100% sensitivity. Also assume that liver-

*Assumes adequate clinical skills and state-of-the-art technology

TABLE 3-2

STRENGTHS AND WEAKNESSES OF MEDICAL SCREENING TOOLS*

Interim MedicalHistory

Limited PhysicalExamination

Sensitivity + +/– ++ ++

Specificity + +/– – – ++Low Cost ++ ++ +/– +/–

Acceptability ++ ++ +/– +/–

Ease of Performance ++ ++ +/– +/–

Accuracy +/– +/– ++ ++

Reproducibility +/– +/– ++ ++

Biological MonitoringLaboratory Procedure


78

Fig. 3-6. A visual representation demonstrating the mathematical relationships among positive and negative test results anddisease presence or absence. The relationships are dependent on test sensitivity and specificity and on disease prevalence.Figure: Courtesy of David F. Cruess, PhD, Professor, Department of Preventive Medicine and Biometrics, F. Edward HébertSchool of Medicine, Uniformed Services University of Health Sciences, Bethesda, Md; 1993.

Sensitivity: the probability that if someone has the disease, he or she will test positive. Sensitivity =

Specificity: the probability that the test will be negative given the absence of the disease. Specificity =

Positive Predictive Value: the probability that someone with a positive test will actually have the disease. Positive Predictive Value =

Negative Predictive Value: the probability that someone with a negative test will not have the disease. Negative Predictive Value =

AA+B

DC+D

DB+D

AA+C

+ = Test Positive

= Test Negative–

A = True Positive

B = False Positive

C = False Negative

D = True Negative

Sen

sitiv

ity S

cale S

pecificity Scale

100% 0

0 100%

– – – – – – – – – – – – + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++ + + ++ + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Disease AbsentDisease Present

C

A

B

Prevalence Scale

– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –

D

function tests have a specificity of 90%. The results of100 liver-function tests in this population would be 5true positives and 10 false positives. The positivepredictive value would be 5 true positives out of a totalof 15 positives, or 33%. This example does not includethe prevalence of non–job-related liver disease (cer-tainly not an uncommon entity), which would reducethe positive predictive value for job-related diseaseeven further. Using low-specificity screening (such asliver-function tests) often results in expensive, time-consuming follow-up. Obviously, selecting a morespecific screening tool is one solution to this problem.Being very specific in the population selected forscreening (that is, doing liver-function tests on those

workers who report changes in alcohol tolerance andare known to be exposed to hepatotoxins) is another.

The most valuable medical screening tool is theinterim occupational and medical history, which isused throughout the employee’s participation in theEmployee Health Program. In most cases, the interimhistory constitutes the only screening necessary formedical surveillance because the army’s workforce isrelatively healthy and job-related illnesses are rare. Awell-constructed interim history can

• confirm information about an individual’s job,• confirm the employee’s use of personal pro-

tective devices,


79

• confirm exposure history,• determine possible changes in health status,• determine the need for further screening,• establish an appropriate relationship with the

employee,• observe the employee for signs of decreased

fitness, and• provide the employee with job-specific health

education.

A limited physical examination directs the physi-cian to look for specific findings that the interimhistory or published medical standards have alreadysuggested. By limiting the examination to targetorgans, the specificity increases and the examinationbecomes useful for medical surveillance. But simplyinstructing a physician to administer an examinationwith emphasis on a specific organ system does notalways direct the physician sufficiently. For example,published medical surveillance guidance for workerswho are exposed to isocyanates recommends an an-nual examination “with emphasis on the respiratorysystem.”23 Such guidance is inadequate. If the exam-ining physician is unaware that isocyanates are pul-monary sensitizers that cause job-related asthma, heor she may examine the patient on Monday morning(before exposure has occurred) and note normal find-ings on chest auscultation. But if the physician hadbeen advised to listen for wheezing after exposure toisocyanates, the examination could have been con-ducted after the worker was exposed on Wednesdayafternoon. This examination, directed toward a spe-cific finding, might also be quicker and easier. Justexamining the chest is completely different from spe-cifically listening for wheezing after an exposure to aknown pulmonary sensitizer.

Diagnostic laboratory screening tests are the thirdmedical screening tool. For laboratory screening to beeffective, the test’s specificity is of paramount impor-tance. A battery of tests on a group of employeesbased on their job description, or on the presumptionof exposure, can be costly (the cost of initial andfollow-up testing) and quite likely will not discrimi-nate between true positive results (which could indi-cate a job-related health effect) and false positive re-sults (which are either spurious or have nothing to dowith the job). Diagnostic laboratory screening is notable to detect all of the sentinel target organ effects onhealth (such as most early cancers), and one-timescreening values, regardless of whether they are nor-mal or abnormal, are often useless.

Even though published medical surveillance guid-ance (for example, DoD Manual 6055.5-M) for specifichazards includes a comprehensive list of laboratory

tests, this information—because it is so broad andnonspecific—may or may not be valuable. Manymedical personnel conclude, erroneously, that be-cause the lists are published by experts, physicians aretherefore obligated to perform all the tests listed foreach specific exposure. However, the guidelines ad-dress all potential exposures; professional judgment isessential. The only professionals who can determinewhich tests are necessary are the physician, the nurse,or the physician’s assistant, who have talked to theemployee, visited the employee’s workplace, and de-termined the possible health effects for which a diag-nostic screening test is indicated and available.

Biological monitoring includes all of the same char-acteristics as diagnostic laboratory screening and canalso measure a toxic agent or its metabolites in abodily fluid. Biological monitoring can be an excellentmedical surveillance tool because of its high specific-ity, but such monitoring is available for very fewoccupational hazards (for example, for lead, bloodlead; for benzene, urine acetone; and for polycyclicaromatic hydrocarbons, specific DNA adducts). Au-diograms can also be used as medical surveillancetools to monitor for exposure to noise.

Timing the Screening

The timing of medical screening is essential. Screen-ing is conducted before job assignments are made,periodically during employment, and on terminationof employment. It also can be conducted in conjunc-tion with the preplacement examination in order toprovide baseline data for comparison with futuresurveillance data, and to document the preexposurehealth status. Periodic medical screening is conductedat routine intervals and should always include aninterim history. The content of periodic screeningneed not always include the entire spectrum of screen-ing tests, but the appropriate tests should be selectedbased on the interim history, the latency period of themost likely health effect, and the time required forphysiological or physical changes to be of sufficientmagnitude for detection.

To determine the appropriate time of the day or theweek for screening, the occupational health physicianmust consider the reason for the screening. For ex-ample, in searching for long-term cumulative effects,or in documenting fitness to work, screening mightbest be conducted early in the day and early in theweek, to decrease the likelihood that test results willreflect transient effects. Hearing tests, for example,are done after a 48-hour quiet period (such as a week-end). However, if acute effects are being sought, or ifthe extent of exposure is being documented, screening


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both later in the day and later in the week may be moreappropriate. Thus, the easiest way to ensure thatscreening is appropriate is to (a) conduct the initialinterview at any convenient time, and then (b) conductfurther screening at a specifically appropriate time.

Using Medical Surveillance Results

The success of a medical surveillance programdepends on how the collected data are used. Whetherthe data show normal or abnormal findings, the re-sults must be used to prevent any negative job-healthinteraction. Normal medical screening results, forexample, can be used as a basis for comparison withfuture screening, for altering the content of futurescreening, for documenting that the employee is fit forwork, and for ensuring that control measures areadequate.

Abnormal screening results require more action.First, the physician, physician’s assistant, or nursemust inform the employee of the results and recom-mend appropriate medical follow-up. If, after thefirst-level screening, a diagnosis or relationship to thejob cannot be determined, the staff must conduct morecomprehensive testing until a negative job–healthrelationship is either verified or eliminated. Further-more, when abnormal findings demonstrate that anemployee is unfit for work, according to either medi-cal standards or physical requirements, the staff mustwork with the Civilian Personnel Office and recom-

mend a job change.When published medical standards do not exist,

the staff must use their professional judgment aboutthe possible relationship between screening resultsand the job. However, if surveillance results indicatethat the job has affected an employee’s health, then thestaff cannot assume that only one employee is at risk.They must assume that a sentinel event has beendetected and vigorously pursue surveillance of thepotentially at-risk population. In addition, the staff,together with the industrial hygienist, safety officer,and engineer, must intervene at the job site to

• substitute nonhazardous substances;• reduce exposure with engineering controls;• reduce exposure with administrative controls;• limit internal doses by using PPE, and;• when necessary, remove employees from the

job.

Far too often, occupational health staff are unin-formed. They equate medical surveillance with occu-pational health. Furthermore, they equate medicalscreening with medical surveillance. While both areclearly very important to the Employee Health Pro-gram, if they are not (a) performed with insight andplanning and (b) followed up with prevention-ori-ented actions, not only are time and money wasted, butthe job-related health effects that are occurring may beundetected until it is too late to help the workers.

OCCUPATIONAL HEALTHCARE SERVICES

A number of Employee Health Programs, includ-ing those for medical, dental, and veterinary person-nel, provide preventive medicine services based onthe concept of surveillance, including (a) the Em-ployee Health Program for healthcare workers, (b)health education, (c) health promotion, (d) adminis-trative medical examinations, (e) monitoring absencesdue to illness, (f) job-related immunizations, (g) repro-ductive-system surveillance, (h) surveillance of per-sonnel with chronic diseases or physical disabilities,and (i) epidemiological studies.

Other health services are clinical, including (a) emer-gency treatment of illness and injury and (b) preven-tion and control of alcohol and drug abuse. All ofthese preventive measures generate a great deal ofinformation about the employee’s health status thatmust not only be documented in records and reportsbut also be used to support the ultimate goal of theprevention of negative job-health interactions.

Preventive Medicine Services

The Employee Health Program for HealthcareWorkers

Due to the wide range of potential health hazardspresent in healthcare facilities, healthcare personnelmust also be included in the installation’s EmployeeHealth Program. Compared to the total civilianworkforce, hospital workers have a higher rate ofworkers’ compensation claims for sprains and strains,infectious and parasitic diseases, dermatitis, hepati-tis, mental disorders, eye diseases, influenza, andtoxic hepatitis.24

Some of the health hazards encountered in thehealthcare environment differ from the hazards atinstallations, but the Employee Health Program forhealthcare personnel is the same as that for otherworkers. Furthermore, the same staff provides em-


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ployee health services to both populations. The pro-gram attempts to achieve two objectives: first, to pro-vide a safe and healthy working environment; andsecond, to assist the employee in maintaining optimalhealth and efficiency in his or her job.

Infectious diseases are a major concern forhealthcare personnel. Not only can infections betransmitted to healthcare personnel, but through them,secondary transmission to patients can also occur. Closecoordination with the infection-control nurse and theinfection-control committee, continuing education,and environmental control, are required in the MTF.Strict compliance with regulations and with the guid-ance of the infection-control program is essential.These regulations include

• DoD 6055.5-M, Occupational Health SurveillanceManual;

• U.S. Army Environmental Hygiene Agency(USAEHA) Technical Guide 143, Evaluation ofOccupational Exposure to Ethylene Oxide inHealth-Care Facilities, which will be publishedin Technical Bulletin Medical (TB MED) 512;

• USAEHA Technical Guide 149, Guidelines forthe Preparation, Administration, and Disposal ofCytotoxic Drugs;

• TB MED 510, Interim Guidelines for the Evalua-tion and Control of Occupational Exposure toWaste Anesthetic Gases; and

• AR 40-14, Control and Recording Procedures forExposure to Ionizing Radiation and RadioactiveMaterials.

Employees who work in hemodialysis units, bloodbanks, and biological laboratories face significanthealth risks as the result of occupational exposures toblood and other potentially infectious materials thatcontain blood-borne pathogens. Blood-borne patho-gens include the hepatitis B virus, which causes hepa-titis B, and the human immunodeficiency virus (HIV),which causes the acquired immunodeficiency syn-drome (AIDS). Hepatitis B is the major infectious occupa-tional health hazard in the healthcare industry. Both thehepatitis B virus and the HIV virus can lead to anumber of life-threatening conditions including can-cer. (The risks associated with these blood-bornepathogens are discussed further in Chapter 5, HealthHazards to Healthcare Workers.) OSHA is currentlydeveloping an exposure standard for occupationalexposure to blood-borne pathogens.

Certain aspects of the Employee Health Programare important to healthcare personnel because theycan help prevent nosocomial infections, including

immunizations, monitoring absences due to illness,and pregnancy surveillance, which are discussed laterin this chapter. Monitoring absences due to illness isespecially important in controlling the spread of infec-tions from healthcare personnel to patients, and toidentify and document the occupational diseases thatare transmitted from patients to employees. The trans-mission of infections signals that prevention mecha-nisms may not be operating optimally and may dic-tate that an epidemiological investigation be initiated.

Healthcare personnel are at risk for potential expo-sure to chemical, physical, and biological hazards. Asin any other work area, the industrial hygienist mustdevelop a comprehensive health-hazard inventorythat identifies the hazards in the MTF. (These hazardsare addressed in Chapter 4, Industrial Hygiene.)

Employee Health Education

Job-related health education, which trains employ-ees about the health hazards associated with theiroccupations, is mandated by law and is primarily theresponsibility of supervisors.20,25 They need the sup-port of several disciplines—safety, nursing and medi-cine, industrial hygiene—and the civilian and mili-tary personnel office training staff to adequately traintheir employees regarding the diverse hazards of thework environment.

The nurses and physicians educate the employeesregarding the health consequences of workplace haz-ards. The information they provide should includethe signs and symptoms of exposure to each hazard,the appropriate emergency medical treatment for acuteexposure to each hazard, the required medical sur-veillance for each hazard, and the necessity for PPE orclothing for each hazard. The Employee Health Pro-gram staff may provide job-related health educationindividually during job-related health evaluations, orto groups of employees who are exposed to the samehazards. Documentation of the education is requiredin the occupational medical record.5

Job-related health education also encompasses otherareas that need the support of the Employee HealthProgram staff. These include

• orientation and guidance of supervisors re-garding their responsibilities for employeehealth,

• orientation of employees to the services thatthe Employee Health Program provides, and

• modification of the work practices that can bechanged by health education to prevent injuryor illness.


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Physicians and nurses also provide general healtheducation to assist the employee to achieve optimalhealth. This education is usually given at the time thatthe employee receives healthcare or approaches theemployee health staff with questions or problems.Small-group sessions may address specific conditionsor habits when a group of workers is identified to havea common problem and help is requested. Groupeducation may be especially effective in dealing withhealth problems or habits such as diabetes (or otherchronic diseases), obesity, and smoking.

Healthcare personnel may distribute educationalpamphlets to employees as a supplement either togroup sessions or to individual education. This willhelp to reinforce the training provided. They may alsopublish health information as articles of interest withinthe installation, which can be disseminated to theemployee population.

Health Promotion

The U.S. Army Health Promotion Program, aninstallation command program, is designed to pro-mote and maintain the physical well-being and fitnessof both military personnel and civilian employees.26

Although civilian employees are encouraged to par-ticipate in fitness and exercise programs, only em-ployees in jobs with physical fitness requirements,like firefighters, will be granted regular time off fromwork to participate in physical fitness training.

The commander may approve up to 3 hours ofadministrative leave per week to allow other civilianemployees to participate in command-sponsoredphysical fitness exercise training, monitoring, or edu-cation. These activities must be an integral part of atotal fitness program and be limited to 6 to 8 weeks induration. Employees may, however, participate inthese programs in their off-duty time.

The physical fitness program responsibilities of theEmployee Health Program staff are minimal. Theymay provide medical examinations for the employeesin jobs that have physical fitness standards in orderto determine their ability to participate in an exerciseprogram. The occupational health nurse may referemployees or may seek consultation from the healthpromotion program staff for certain programs suchas nutrition or smoking cessation, in order to providethese in the Employee Health Program.

The Employee Health Program services include healthpromotion activities such as (a) small-group counseling,(b) mass disease screening, and (c) voluntary healthmaintenance examinations. All health promotion ac-tivities for civilian personnel are the lowest priorityand are offered only when the resources are available.

Small-Group Counseling. The occupational healthnurse may conduct small-group counseling sessionson specific problems or habits that affect employeehealth. Before planning these programs, it is essentialto perform a needs assessment (that is, to determine theperceived medical needs and interests of the employ-ees). Small-group counseling programs require theirparticipants to make a lifestyle or a behavioral change.The programs must be designed to help individualsadopt positive health-related behaviors, such as smok-ing cessation, stress management, and good nutrition,to help them attain a higher level of well-being. Theplanners of these programs should optimally utilizeavailable MTFs, installations, or local communityhealth resources such as the American Heart Associa-tion or the American Cancer Society.

Mass Screening for Diseases. Another voluntaryhealth promotion activity that the Employee HealthProgram may perform is mass screening for diseases—either single-disease or multiphasic-disease screen-ing. Single-disease screening may detect one medicalcondition such as high blood pressure, whilemultiphasic-disease screening offers tests such as thosefor blood sugar, hearing, and vision. In planning amass screening, coordination with the MTF and othercommunity resources can be advantageous. In addi-tion, the following questions need to be considered:

• Do the prevalence and seriousness of the dis-ease or condition justify the cost of interven-tion?

• Is the procedure appropriate to the healthgoals of the age group, and is it acceptable tothe population?

• Is the procedure relatively easy to administer,easy to interpret by healthcare professionals,and available at reasonable cost?

• Are resources available for follow-up diagno-sis or therapeutic intervention?

• Will appropriate referrals be made as indi-cated?

• Is there an evaluation of the mass screeningprogram’s effectiveness?

Health Maintenance Examinations. While healthmaintenance examinations can be offered to civilianemployees, they are not a requirement for the job;however, employees are encouraged to participate.The examinations should be tailored to specific healthgoals and professional health services that are appro-priate for different age groups, rather than perform-ing identical tests and examinations for the entireemployee population. Regardless of the scope of theexaminations, appropriate follow-up is crucial.


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Administrative Medical Examinations

A basic premise of employment by the federalgovernment is that employees must be fully qualifiedto perform the essential duties and responsibilities oftheir positions safely and efficiently, without unduerisk to themselves or others. However, employeesneed to have only the minimum physical abilities thatare necessary to fulfill this requirement. The purposeof performing an administrative medical examinationis to determine the employee’s physical and mentalability to perform the job. Management needs thisinformation to make employment decisions: virtuallyall employment-related decisions involving anapplicant’s health status are made by management,not by physicians. The role of the examining physi-cian in employment decisions is limited to determin-ing the stability of the individual’s medical conditionand whether the individual meets the medical re-quirements of the job.

The Office of Personnel Management has estab-lished medical standards and physical requirements for afew specific jobs.27 Medical standards describe (a) theminimum health status or fitness level that has beendetermined to be necessary for safe and efficient per-formance and (b) the medical conditions that are con-sidered to be disqualifying for certain jobs. Physicalrequirements differ from medical standards in thatthey describe the physical abilities that an employeemust have to perform the tasks included in a job, suchas the ability to lift 50 lb.

The types of physical examinations that are admin-istrative include (a) preplacement examinations, (b)periodic examinations, (c) fitness-for-duty examina-tions, and (d) disability retirement examinations.

Preplacement Examinations. Preplacement exami-nations (that is, examinations that are performed be-fore the employee commences working) enable theoccupational health physician to assess the employee’sphysical abilities and limitations with respect to jobrequirements, and to document baseline data for fu-ture use in the evaluation of potential workplaceexposures. Preplacement examinations also identifysusceptible individuals who might be at higher riskfor developing diseases related to specific occupa-tional exposures; for example, people of Mediterra-nean heritage can develop hemolytic anemia afterbeing exposed to reducing agents, whereas their simi-larly exposed but non-Mediterranean coworkers willnot. This helps to ensure that employees’ job place-ments are safe.

Office of Personnel Management policy limits man-datory preplacement medical examinations to per-sonnel who are applying for positions that have spe-

cific physical fitness standards, potentially hazardousduty exposures, or when the examination is requiredby the employing agency.27 The local Civilian Person-nel Officer determines the positions that requirepreplace-ment health evaluations. Generally, mostwage-grade positions are considered arduous or haz-ardous and require a preplacement examination.28 Bycomparison, GS positions are considered light dutyand do not require a preplacement examination, ex-cept for a few occupational series.11

The local occupational health physician determinesthe specific content of preplacement examinations.The physician must consider the duties and require-ments of the position including environmental fac-tors, legal and regulatory requirements, and any otherfactors that are directly relevant to determining theapplicant’s ability to perform the job safely and effi-ciently. Additionally, if the applicant is assigned to awork environment that is potentially hazardous to hisor her health, the occupational health physician mustadminister baseline screening tests and examinations(an audiogram for noise exposure or an electrocardio-gram for nitroglycerin exposure) that are specific tothe hazards. All assessments should include

• a personal and family health history, includ-ing a reproductive history for both men andwomen, and a smoking and alcohol history;

• a detailed work history, including the lengthof employment in each job and the nature andduration of exposure to hazardous conditions;and

• a general medical history.

Certain forms must be completed to document theadministration and findings of the preplacement ex-amination. The SF 78, Certificate of Medical Examination,and the SF 93, Report of Medical History, are required forall appropriated-fund applicants who are required toundergo a preplacement examination. Similarly, DAForm 3437, Certificate of Medical Examination, and theSF 93 are required for nonappropriated-fund appli-cants. The Civilian Personnel Office usually forwardsthe SF 78 and DA Form 3437 to Employee HealthProgram staff members, indicating the specific job’sphysical requirements and environmental factors.

Although the Office of Personnel Management doesnot require a preplacement examination for appli-cants for positions with duties that are usually seden-tary or only moderately active, these applicants mustcomplete forms prior to employment to establish theirmedical qualifications. Appropriated-fund applicantsmust complete the SF 177, Statement of Physical Abilityfor Light Duty Work and nonappropriated-fund appli-


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cants must complete DA Form 3666, Statement of Physi-cal Ability for Light Duty Work. Even though apreplacement examination is not required for light-duty workers, Employee Health Program personnelmust obtain a general medical history for these appli-cants using the SF 93, Report of Medical History. Baselinescreening, such as for blood pressure, vision, andhearing, is recommended if resources are available.Additionally, hazard-specific baseline screening testsmust be done if the light-duty applicant will be as-signed to a potentially hazardous work environment.

Periodic Examinations. The purpose of adminis-trative periodic examinations is to verify an employee’scontinuing ability to perform the job. However, thepurpose of periodic job-related examinations is todetermine the effect of the job on the health status ofthe employee. Although the Office of Personnel Man-agement specifically requires that only a few positionshave periodic examinations, it is good occupationalhealth practice to perform annual examinations on allemployees whose positions have medical standardsor physical requirements.27,29,30 Several ARs addressperiodic examinations, including AR 420-90, Fire Pro-tection; AR 190-56, The Civilian Police and Army SecurityGuard Program; and AR 600-55, Motor Vehicle Driverand Equipment Operator Selection, Training, Testing, andLicensing.

The administrative periodic examination requiresthat the Employee Health Program staff record theresults. For appropriated-fund civilian employees,either the SF 78, Certificate of Medical Examination, orSF 88, Report of Medical Examination, is used to re-cord results. The results of administrative periodicexaminations for military personnel are recorded onlyon SF 88.

Fitness-for-Duty and Disability Retirement Ex-aminations. Fitness-for-duty and disability retire-ment examinations determine the employee’s contin-ued capability to meet the physical or medicalrequirements of a position.27,31 A federal agency mayoffer a medical examination that includes a psychiat-ric evaluation or psychological assessment, or it mayrequest the employee to submit medical documenta-tion in any situation in which it is in the government’sinterest to obtain medical information that is relevantto an individual’s ability to perform safely and effi-ciently. Whenever an agency either orders or offers amedical examination, or requests medical documen-tation, the employee must be informed in writing ofthe following:

• the reasons for the examination,• the individual’s right to submit medical infor-

mation from his or her own physician, and

• the agency’s obligation to consider informa-tion from the individual’s physician.27

The employee must submit medical documenta-tion when a change in duty status, working condi-tions, or any other benefit or special treatment formedical reasons is requested. The agency requestingthe medical examination or documentation must paythe reasonable costs that are associated with obtainingthe examination or information. Should the employeerequest the examination while in the process of apply-ing for a benefit or special consideration (such asextended sick leave or reassignment), the employee isresponsible for paying the cost of the examination.27

The supervisor is responsible for making requestsfor fitness-for-duty examinations through the Civil-ian Personnel Office. The Civilian Personnel Officethen forwards all background data that pertains to therequest to the Employee Health Program staff. Thisinformation is essential for the physician to make avalid medical determination.

Monitoring Absences due to Illness

Supervisors and the Civilian Personnel Office areresponsible for absentee personnel. However, theEmployee Health Program staff should contributesignificantly to keeping employees healthy and presenton the job, to minimize the cost of the time lost becauseof absences due to illness. Medical monitoring en-sures that the employee is well enough to perform hisjob safely, but it is not a means to monitor the use ofsick leave. At no time should the Employee HealthProgram staff be requested or used to check on sus-pected malingerers when they are out of work onpersonal, sick, or workers’ compensation leave. Theidentification and control of the abuse of leave ben-efits is a supervisory and Civilian Personnel Officeresponsibility. Management, employees, and unionsshould understand this for the monitoring of absencesdue to illness to be effective.

The requirement and responsibilities for monitor-ing absences due to illness must be included in theinstallation occupational health regulation so that themedical aspects can be implemented. The medicalmonitoring of absences due to illness includes evalu-ating, treating, or referring employees who become illor are injured during duty hours. The purposes of thisservice include the appropriate disposition of ill em-ployees, the staff’s provision of health education, andthe staff’s increased awareness of the types of healthproblems in the employee population. The monitor-ing program also increases the staff’s capability todetect sentinel job-related health effects by knowing


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the reason for employees’ absences from work. (Man-hours can also be conserved if palliative treatment isprovided for minor illnesses or injuries and employ-ees are able to quickly return to their jobs.)

The Employee Health Program staff should evalu-ate the health status of civilian employees who arereturning to work after an absence due to illness.5 Thisevaluation is essential whether or not the absence wasoccupationally related: it ensures that the employee iswell enough to work. The results of the evaluationmay reveal that the employee cannot return to his orher regular job, but is able to perform some other typeof work. The occupational health physician can thenrecommend work limitations. An evaluation after anabsence due to job-related illness is also essential todocument the accident or illness accurately in theoccupational health record.

The occupational health physician and the CivilianPersonnel Office determine the duration of the absencesand the illnesses that require an evaluation for all personnelexcept those who are off due to job-related cases,personnel in patient-care positions, and personnel whohandle food. These employees are required to reportto the staff for evaluations after any illness.5 As a rule,instructing all other employees to clear through theEmployee Health Program after a nonoccupational ab-sence due to illness that is longer than 5 working dayswill meet the medical monitoring objective withoutoverburdening the Employee Health Program staff.

Monitoring absences due to illness includes per-forming medical evaluations when they are necessaryin support of the Federal Employee’s CompensationAct claim controversions (that is, legal actions that aretaken when the employer does not agree with theemployee that a compensable illness or injury hasoccurred). Medical evaluations are also necessary foremployees who are expected to be absent from workfor 2 or more weeks due to a job-related illness orinjury.5 These evaluations may require only a reviewof medical reports or they may call for an appropriateexamination. The occupational health physician shouldrequest specialty consultation when it is indicated.

Immunizations

Some occupational settings may increase anemployee’s risk of infection. For example, the poten-tial for increased exposure to biological hazards existsin hospitals, medical and dental clinics, animal-carefacilities, child-care centers, biological research labora-tories, and waste-disposal facilities. Employees whotravel to foreign countries in an official capacity arealso considered to have an increased risk of infection.

The immunization program for healthcare person-

nel provides those who are at risk with appropriateimmunizations and chemoprophylaxis. An OTSGpolicy letter mandates hepatitis B immunizations forall active-duty members of AMEDD.32 This policyletter also advises that civilian healthcare personnel atrisk should individually be encouraged to be immu-nized, unless immunization is specifically mandatedin their work agreements or job descriptions. Inaddition to hepatitis B immunizations, the EmployeeHealth Program may provide

• rubella, tetanus, and influenza immunizationsfor medical and dental personnel;

• rabies prophylaxis for veterinary staff andanimal handlers;

• specific vaccinations for the staff who workwith pathogens in research and medical labo-ratories; and

• tuberculosis screening for high-risk dental,medical, and veterinary personnel.

The staff provides or arranges for appropriate im-munizations, chemoprophylaxis, and other preven-tive measures against communicable diseases such astetanus, rubella, and tuberculosis. Before determiningwhich immunizations and chemoprophylaxes shouldbe offered to civilian personnel, the occupational healthphysician must assess the specific biological hazardand the potential effectiveness of a vaccine to controlthe problem. The occupational health physician shoulduse the current Recommendations of the ImmunizationPractices Advisory Committee, which is published bythe U.S. Public Health Service, Centers for DiseaseControl, as a reference in making these determina-tions. Immunizations for military personnel mustcomply with AR 40-56233 and guidance from the OTSG.

The staff may also offer immunizations that are notjob-related. For example, influenza immunizationsare offered to civilian personnel in an effort to reduceabsenteeism due to illness.

Surveillance of Employees Exposed to ReproductiveHazards

Surveillance minimizes occupationally engenderedrisks to the health of the pregnant employee and herfetus, and to the health of the reproductive system ofthe male employee. Therefore, this surveillance mustinclude both male and female civilian and militaryemployees, because the biology of reproduction dem-onstrates clearly that both males and females are atrisk from workplace hazards to the reproductive sys-tem,34 and is emphasized for nursing, dental, medical,and veterinary personnel.


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In addition to evaluating pregnant women for po-tential exposures to chemical, physical, and biologicalhazards, exposures to nosocomial hazards (such ascytomegalovirus, herpesvirus, and rubella) in the MTFmust also be evaluated. Pregnant women shouldavoid unnecessary or regular contact with patientswho either have hepatitis or who could be carriers ofthe hepatitis virus: maternal infection with hepatitis Bvirus in the latter stages of pregnancy may causesignificant illness and death to the newborn.

A pregnancy surveillance program is the responsi-bility primarily of the occupational health nurse, inaccordance with guidelines that the occupational healthphysician develops. The NIOSH Research Report isan excellent reference for pregnancy surveillance.35

One of the first steps in implementing a pregnancysurveillance program is for the occupational healthnurse to coordinate with the Civilian Personnel Officeand supervisors in instituting a policy and procedurethat ensures that civilian workers contact the Em-ployee Health Program staff as soon as they knowthey are pregnant. The program for military womenshould be coordinated with the obstetrical or gyneco-logical nursing staff or the community health nurse.

Work areas or occupations that contain potentialhazards to the reproductive system must be identifiedthrough the health-hazard inventory developed by theindustrial hygienist. All female employees who are ofchildbearing age and all male employees who areassigned to these areas must not only be informed thatpotential hazards to their reproductive systems exist,but also be informed of the effects of those hazardsduring their preplacement, periodic, and terminationexaminations.5 Any history of infertility should alsobe evaluated from an occupational standpoint. Womenmust be provided information on the availability ofjob accommodation or transfer in the event of preg-nancy, if this is necessary to protect the mother or herfetus. In addition, the potential hazards to the repro-ductive system that are identified and the educationand counseling that are provided must be documentedin the individual’s occupational medical record.

When an employee contacts the Employee HealthProgram staff to inform them of her pregnancy, a nurseor physician must interview the employee and docu-ment a health and work history. The staff must deter-mine at that time if the employee may continue work-ing safely in her current job. In addition, the staff mustobtain and record data in the employee’s occupationalmedical record. These data include the expected dateof confinement, previous pregnancies, home expo-sures, hours of work, and other pertinent information.

If the environment is safe, the Employee Health

Program staff need not periodically follow up thisinitial evaluation. However, the interviewer shouldadvise the employee during the initial evaluation that theoccupational health nurse should be contacted imme-diately if any changes occur in her work environment.

Coordination between the Employee Health Pro-gram staff and the pregnant employee’s attendingphysician is essential. The occupational health physi-cian is familiar with the demands and exposures of thejob, but the attending physician might be unfamiliarwith the potential hazards that are present in theemployee’s work environment. When questions thatare related to the safe job placement of a pregnantemployee arise, a discussion will lead to a more validmutual decision as to whether the employee maycontinue to work in her present position or will re-quire a transfer for job accommodation.

The coordination between the employee’s physi-cian and the Employee Health Program staff contin-ues even after the employee’s pregnancy. While theemployee’s attending physician must clear theemployee’s return to work after maternity leave, theoccupational health nurse must also evaluate the em-ployee. The occupational health nurse should evalu-ate the pregnancy outcome and document the resultsin the employee’s medical record.

Surveillance of Employees with Chronic Diseases orPhysical Disabilities

Surveillance of personnel with chronic diseases orphysical disabilities ensures that the employees’ opti-mal health status is maintained and that no adverseeffects result from interactions of the job with thechronic illness or disability. If this surveillance iseffective, these employees can remain active membersof the workforce.

The staff should identify employees who havechronic diseases or disabilities that may affect or beaffected by their work assignments. This can beaccomplished by

• reviewing SF 177, Statement of Physical Abilityfor Light Duty Work;

• reviewing SF 93, Report of Medical History;• performing preplacement, periodic, and re-

turn-to-work examinations; and• performing mass screening programs.

Once employees with chronic diseases or physicaldisabilities have been identified, standard medicalpractice dictates that they be medically evaluated todetermine their work capabilities and to ensure safe


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job placement. If the evaluation indicates that theemployee is unable to perform all of his or her jobduties, the Employee Health Program staff shouldnotify the employee’s supervisor.

The frequency of follow-up evaluations varies de-pending on the employee’s specific condition. Afollow-up evaluation may consist of either a tele-phone call by the Employee Health Program staff tothe employee to inquire about the health status and tooffer counsel, or a visit by the employee to the em-ployee health service for further evaluation and coun-seling. During these evaluations, the employee shouldinform the staff of any changes in his or her condition.

The staff should document medical evaluations inthe employee’s medical record. Documentation shouldinclude clinical data regarding the disease or physicaldisability, its current treatment, and the name of theemployee’s personal physician. DA Form 5571, Mas-ter Problem List, is used to document current diagnosesand medications used currently or recently. The staffshould update this information whenever the em-ployee is examined or counseled.

Epidemiological Investigations of OccupationalIllnesses and Injuries

Epidemiological investigations must be conductedafter a suspected or proven occupational illness hasoccurred and after excessive numbers of occupationalinjuries have been identified.5 For example, CTS amongworkers in specific job categories such as clerks andcomputer operators has recently been a topic of con-cern (Figure 3-7):

CTS results from repetitive flexing and bending of thewrist, which causes tendons to swell, increasing pres-sure in the carpal channel and pinching the mediannerve.36

The association between the illness or injury andthe potential presence of an unhealthy or unsafe workenvironment is evaluated in an epidemiological in-vestigation. Inquiries must extend beyond individualcases to the identification of the total population atrisk for the same illness or injury. The investigationmust be coordinated with the industrial hygienist andother preventive medicine personnel as needed, safetyofficials, and other personnel who may have a respon-sibility or an interest in the nature and the magnitudeof the problem.

Epidemiological investigations range from a simplereview of the individual’s work and health historywith an evaluation of the exposure at the worksite, to

a detailed study involving sampling and laboratoryanalysis of suspected agents, medical examinationsand tests, and a literature review. Frequently, inves-tigations require the assistance of the supporting medi-cal center. If the MEDCEN's capabilities are limited,epidemiological consultation is available through com-mand channels from the USAEHA and the WalterReed Army Institute of Research.5

Clinical Services

Clinical services are also provided to civilians whowork for the army, including (a) emergency treatmentof illnesses and injuries and (b) alcohol and drug-abuse prevention and control programs. (The latter isincluded in this section because it can be clinicallyrelevant; however, the cause is not considered to bejob related.)

Emergency Treatment of Illnesses and Injuries

Civilian employees are generally not eligible fordefinitive diagnoses and treatments of nonoccupationalinjuries and illnesses under the Employee Health Pro-gram. However, there are two exceptions to this. First,in an emergency, the civilian employee will be giventhe medical attention that is required to prevent theloss of life or limb, or to relieve suffering until he or shecan be cared for by a private physician. And second,civilian employees may also be treated for minordisorders, including first aid or palliative treatment,when the employee would not reasonably be ex-pected to seek attention from a private physician. Thisreduces absences due to illness by enabling the em-ployee to complete the current workshift before con-sulting a private physician. However, requests forrecurrent treatment of the same nonoccupational dis-orders are discouraged. If continued care is neces-sary, the employee should be referred to his or herprivate physician.

Minor treatments or services for nonoccupationalconditions, such as administering allergy injections,monitoring blood pressure, and changing dressings,can be provided at the discretion of the occupationalhealth physician in charge. Requests for allergy injec-tions must be submitted in writing and signed by theemployee’s private physician, and the employee mustprovide the medications that are required. Theseservices are provided so that lost work time can beavoided.

Arrangements for emergency medical care duringnonduty hours of the MTF should be made for thoseemployees who work hours other than the normal day


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Fig. 3-7. The section through the wrist at the distal row of carpal bones shows the carpal tunnel. Increase in size of thetunnel structures caused by edema (trauma), inflammation (rheumatoid disease), ganglion, amyloid deposits, ordiabetic neuropathy may compress the median nerve. The person with carpal tunnel syndrome will develop atrophyof thenar muscles due to long-standing compression of the median nerve, will oftentimes experience gradualnumbness of the fingers while driving, and may be awakened at night by tingling and/or pain in the thumb, index,and middle fingers. Reprinted with permission from Netter FH. The CIBA Collection of Medical Illustrations. Vol 1,Nervous System. Part 2, Neurologic and Neuromuscular Disorders. West Caldwell, NJ: CIBA-Geigy; Slide 3485; 212.

shift. Firefighters or guards who are appropriatelytrained may provide emergency care, or employeesmight be referred to nearby community hospitals orphysicians.

Prevention and Control of Alcohol and Drug Abuse

The U.S. Army Alcohol and Drug Abuse Preven-tion and Control Program (ADAPCP) is an installa-tion command-sponsored program that addresses al-cohol and other drug abuses and related activities ina single program. Military employees are not justeligible for the program; participation is mandatory

for all soldiers who are enrolled in the ADAPCP bytheir commanders. Medical services and clinical sup-port for soldiers being treated in ADAPCP are theresponsibilities of the MEDCEN-MEDDAC com-mander. While civilian employees are eligible for theprogram, their enrollment is voluntary. Employeeswith an alcohol- or drug-abuse problem are encour-aged to seek assistance and counsel from ADAPCP.37,38

In the program for civilians, the functions of theEmployee Health Program staff include initial coun-seling, referring employees to treatment resources,and performing the initial medical evaluations ofemployees who enter the program.

Figure 3-7 is not shown because the copyrightpermission granted to the Borden Institute, TMM,does not allow the Borden Institute to grant per-mission to other users and/or does not includeusage in electronic media. The current user mustapply to the publisher named in the figure legendfor permission to use this illustration in any typeof publication media.


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SUMMARY

The U.S. Army operates over 130 Employee HealthPrograms worldwide for its military and civilian em-ployees. Although these programs’ administrativestructure, professional staffing, and areas of emphasisare quite diverse, they all are based on the same set oflaws, DoDIs, and ARs. All have the same basic mis-sions: to prevent negative interactions between the joband the workers’ health and to provide job-related,clinical healthcare services.

The health program for the army’s civilian employ-ees is composed of (a) preventive medicine servicesand (b) clinical services. The preventive elementsinclude job-related medical surveillance, administra-

tive medical examinations, surveillance of employeesexposed to reproductive hazards, monitoring of ab-sences due to illness, surveillance of personnel withchronic diseases or physical disabilities, job-relatedimmunizations, health education, epidemiological in-vestigations, and health-promotion programs. Theclinical elements include treatment of job-related ill-nesses and injuries, palliative treatment of minor ill-nesses, and alcohol- and drug-abuse programs. Be-cause military personnel receive routine healthcarethrough MTFs, job-related medical surveillance is theonly Employee Health Program element that is usu-ally provided to soldiers.

REFERENCES

1. 20 CFR, Part 10(a).

2. US Department of the Army. Insurance and Annuities. Washington, DC: DA; 1983. Army Regulation 690-800, Subchap1-1.

3. US Department of the Army. The Administration of Army Morale, Welfare, and Recreation, Activities and NonappropriatedFund Instrumentalities. Washington, DC: DA; 1988. Army Regulation 215-1.

4. US Office of Personnel Management. Injury Compensation. Washington, DC: OPM; 1988. Federal Personnel Manual,Chap 810.

5. US Department of the Army. Preventive Medicine. Washington, DC: DA; 1990. Army Regulation 40-5.

6. USA Health Services Command. HSC Operating Program—Preventive Medicine Program for MEDCEN/MEDDAC. FortSam Houston, Tex: HSC; 1989. HSC Regulation 40-30.

7. USA Health Services Command. Organization and Functions Policy. Fort Sam Houston, Tex: HSC; 1989. HSCRegulation 10-1.

8. US Office of Personnel Management. Federal Employees Health and Counseling Programs. Washington, DC: OPM; 1986.Federal Personnel Manual, Chap 792.

9. US Department of the Army. Staffing Guide for US Army Medical Department Activities. Washington, DC: DA; 1974. DAPamphlet 570-557.

10. US Department of the Army. Commissioned Officer Classification System. Washington, DC: DA; 1990. Army Regulation611-101.

11. US Office of Personnel Management. Qualification Standards for Positions Under the General Schedule. Washington, DC:OPM; 1986. Handbook X-118.

12. US Department of the Army. Quality Assurance Administration. Washington, DC: DA; 1989. Army Regulation 40-68.

13. US Department of the Army. Nonphysician Health Care Providers. Washington, DC: DA; 1985. Army Regulation 40-48.


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14. US Department of the Army. Medical Record and Quality Assurance Administration. Washington, DC: DA; 1987. ArmyRegulation 40-66.

15. US Office of Personnel Management. Basic Personnel Records and Files System. Washington, DC: OPM; 1987. FederalPersonnel Manual, Suppl 293-31.

16. 29 CFR, Part 1910 § 20.

17. 29 CFR, Part 1913.

18. US Army Health Services Command. Preventive Medicine. Fort Sam Houston, Tex: HSC; 1985. Army Regulation 40-5, HSC Suppl, App H.

19. US Department of the Army. Patient Administration. Washington, DC: DA; 1983. Army Regulation 40-400.

20. Occupational Safety and Health Act of 1970, Pub L No. 91-596.

21. 29 CFR, Part 1960.

22. Last JM, ed. Maxey-Rosenau’s Public Health and Preventive Medicine. 11th ed. New York: Appleton-Century-Crofts; 1980.

23. US Department of Defense. Occupational Surveillance Manual. Washington, DC: DoD; 1985. DoD Manual 6055.5-M.

24. US Public Health Service, Centers for Disease Control; National Institute for Occupational Safety and Health.Guidelines for Protecting the Safety and Health of Health Care Workers. Washington, DC: US Department of Health andHuman Services; 1988.

25. 29 CFR, Part 1910 § 1200.

26. US Department of the Army. Army Health Promotion. Washington, DC: DA; 1987. Army Regulation 600-63.

27. US Office of Personnel Management. Medical Qualifications Determinations. Washington, DC: OPM; 1989. FederalPersonnel Manual, Chap 339.

28. US Office of Personnel Management. Job Qualification System for Trades and Labor Occupations. Washington, DC: OPM;1969. OPM Handbook X-118C.

29. US Office of Personnel Management. Physical Requirements. Washington, DC: OPM; 1979. Civilian PersonnelRegulation 950, App W.

30. US Office of Personnel Management. Physical Standards for Motor Vehicle Operators and Incidental Operators. Washing-ton, DC: OPM; 1986. Federal Personnel Manual, Chap 930, App A.

31. 5 CFR, Part 831 § 502.

32. Office of The Surgeon General. Mandatory Hepatitis B Immunization Policy. Falls Church, Va: US Department of theArmy, 17 April 1989. Memorandum.

33. US Department of the Army. Immunizations and Chemoprophylaxis. Washington, DC: DA; 1988. Army Regulation 40-562.

34. Rom WN, ed. Environmental and Occupational Medicine. Boston: Little, Brown; 1983: 75–83.

35. US Public Health Service, Centers for Disease Control; National Institute for Occupational Safety and Health.Guidelines on Pregnancy and Work. Rockville, Md: USDEW; 1977. NIOSH Research Report. DHEW (NIOSH) Publica-tion 78-118.

36. Ehrlich A. A Pain in the wrist. In: The Baltimore Sun. 29 September 1991; 8.


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37. US Department of the Army. Alcohol and Drug Abuse Prevention and Control Program. Washington, DC: DA; 1988. ArmyRegulation 600-85.

38. US Office of Personnel Management. Alcoholism and Drug Abuse Programs. Washington, DC: OPM; 1980. FederalPersonnel Manual, Suppl 792-2.

US Department of the Army. Employment. Washington, DC: DA; 1979. Army Regulation 690-300. This AR providesdetails concerning the employment of personnel with chronic diseases or disabilities.

US Department of the Army. Nonappropriated Funds and Related Activities Personnel Policies and Procedures. Washington,DC: DA; 1984. Army Regulation 215-3, Chap 16. This AR lists forms used for nonappropriated-fund employees forinitiating compensation claims.

US Department of the Army. Medical, Dental and Veterinary Care. Washington, DC: DA; 1985. Army Regulation 40-3.

US Department of the Army. Accident Reporting and Records. Washington, DC: DA; 1987. Army Regulation 385-40. ThisAR summarizes reporting requirements for the OSHA Log of Occupational Injuries.

US Office of Personnel Management. Employment of the Physically Handicapped. Washington, DC: OPM. 1978. FederalPersonnel Manual, Chap 306, Subchap 4. This chapter of the FPM provides details concerning the employment ofpersonnel with chronic diseases or disabilities.

US Army Environmental Hygiene Agency. Guide for Developing Medical Directives for Occupational Health Nurses.Aberdeen Proving Ground, Md: USAEHA; 1989. Technical Guide 004. This technical guide provides definitive guidancein the preparation and use of medical directives for the nursing staff.

US Army Environmental Hygiene Agency. How to Write and Manage Standing Operating Procedures (SOP). AberdeenProving Ground, Md: USAEHA; 1990. Technical Guide 176. This technical guide provides useful guidance in developingan SOP.

US Army Patient Administration Systems and Biostatistics Activity. Medical Summary Report MED 302 User’s Manual.Falls Church, Va: Office of The Surgeon General; 1987. ADSM 18-HAI-RUD-MUS-UM.

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