MSHA IS SEEKING VENDORS TO PROVIDE QUOTES TO PERFORM PHYSICAL EXAMINATIONS AND AUDIOGRAMS FOR EMPLOYEES.SPECIFICATIONS ARE LISTED FOR REGULAR EXAMS AND MINE RESCUE EXAMS. THE SPECIFICATIONS AND CHECKLIST ARE AS FOLLOWS:1010 Required Elements of Physical Examination: 1. Pre-Placement, Mandatory Periodic, and Termination (Exit) Examinations: (See Appendix D) The SF78, 93, and OSHA Form 22 must be completed and signed by the employee and examining physician (Appendices G-2, G-3, and G-9). Clinical tests to be included: a) Vision Screening ? far, near, depth, color, fields, peripheral, lateral/vertical phoria, monocular, and binocular with and without glasses or contacts, tonometry; b) Vital Signs ? blood pressure, temperature, body height and weight, pulse, skin; c) Laboratory tests to be included: complete blood count (hematology), urinalysis, glucose, cholesterol, chemistry (see FOH work orders 4423, 4513, 4437, or 4455 (Appendix E); d) EKG tracing and interpretation; e) Chest x-ray, report with interpretation of the x-ray, and B-read (Appendices G-6 and G-7); f) Pulmonary function test (Spirometry) with interpretation (3 curves); and g) Audiometry (Frequencies 500, 1000, 2000, 3000, 4000, 6000, and 8000): 14-hour noise free period prior to testing. If there is a Standard Threshold Shift (STS), a repeat test must be given within 14 days. There is to be a doctor-patient discussion of significant findings on the examination. The doctor is to send a copy of the physical examination and tests to the patient and to the MRO. 2. Mine Rescue Team Examination: Note: While many of the clinical and laboratory tests are the same as in pre-placement, mandatory periodic, and termination examinations, the standards are more stringent. The physical examination is done annually and the chest x-ray is done with the physical every third year (See Appendix H ? Mine Rescue Guidelines). The examining physician must conduct an in-depth medical history according to 30 CFR 49.7 Clinical tests to be included: a) Vision Screening: far, near, depth, color, fields, peripheral, lateral/vertical phoria, monocular, and binocular with and without glasses or contacts, tonometry; b) Vital Signs: blood pressure, temperature, body height and weight, pulse, skin; c) Laboratory Tests to include ? complete blood count (hematology), urinalysis, glucose, cholesterol, chemistry [see FOH work orders 4423, 4513, 4437, or 4455 (Appendix E)]; d) EKG tracing and interpretation; e) Chest X-Ray, report with interpretation of the x-ray, B-Read (Appendices G-6 and G-7); f) Pulmonary Function Test (Spirometry) with interpretation (3 curves); and g) Audiometry (Frequencies 500, 1000, 2000, 3000, 4000, 6000, and 8000): 14-hour noise free period prior to testing. If there is a Standard Threshold Shift (STS), a repeat test must be given within 14 days. The exam must include a doctor-patient discussion of positive findings on examination. The doctor is to send a copy of the physical examination and tests to the patient and to the MRO. MSHA Checklist for Periodic/Exit Exams The examining physician must discuss the medical history form (SF 93) and any pre-existing conditions with patient. The examining physician must then address and document any positive medical history, physical findings, and significant abnormal lab values before exam is sent for QA. Ensure that all requested forms and test results are attached! Incomplete forms and missing test results ultimately delay the review which can restrict employees from regular duties. MSHA District Medical Provider Item ? ? Position Description ? ? Self-Addressed Envelope ? Medical Provider must mail COPY of exam to the patient. ? ? FedEx Envelope for ORIGINAL exam addressed to: ATTN: Caitlin Wilkinson Human Resources ? Medical Review Section 1100 Wilson Blvd, Rm 2121 Arlington, VA 22209 Ph 202-693-9759 Fx 202-693-9873 ? ? FOH 6 ? Authorization for Disclosure ? must send original with exam ? ? FOH 9 and FOH 9(a) ? B-read Request/Tracking and B-Read of Chest X-ray ? Only required if Provider DOES NOT have Certified B-Reader ? ? CDC/NIOSH (M) 2.8 ? B-read Interpretation Form ? Provider must document results on this form if using own Certified B-Reader ? ? FOH 17 ? Audiogram History/Report ? ? FOH 22 ? OSHA Respirator Clearance (Part A mandatory, Part B filled out at discretion of examining physician) ? ? SF 78 (Part A completed by employee, Part C completed by Medical Provider) ? Certification of Medical Exam ? ? SF 93 ? Report of Medical History ? ? Baseline Audio Summary ? Audiogram Results ? Must test frequencies of 500, 1000, 2000, 3000, 4000, 6000, 8000 hertz. IF PATIENT WEARS HEARING AIDS, AN AUDIOLOGIST MUST PERFORM THE TEST (with and without aids). Do not perform audiogram if ear(s) blocked (wax, infection, etc.). If baseline summary is missing from exam packet, please contact HQ immediately at the number listed above. The Medical Provider must determine if repeat is necessary and schedule within two weeks (after 14-hr noise-free period). The Provider must notify the District Point of Contact when a repeat audiogram has been scheduled. ? Labwork: Chemistry ? Sodium, Potassium Chloride, Glucose, BUN, Creatinine, Calcium, Total Protein, Albumin, Total Bilirubin, Direct Bilirubin, Alkaline Phosphatase, ALT, GGT, LDH, CRP (LDL, HDL, Glucose, Total Cholesterol, Cholesterol/HDL ratio, Triglycerides). ? Urinalysis: PH, Protein Negative, Glucose Negative, Ketone Negative, Blood Negative, Nitrite Negative, Leukocyte Negative, Urobilinogen, Clarity. ? Hematology: WBC, RBC, HGB, HCT, MCV, MCH, MCHC, RDW-CV, Platelet, MPV, Differential: Neutrophils, Bands 0, Eosinophils, Basophils, Monocytes, Lymphocytes. ? B-read ? If you do not have a certified b-reader, please FedEx original chest x-ray film and radiology report to: Dr. Jonathan Fish Diagnostic Radiology 33 Bonita Avenue Piedmont, CA 94611 ? Chest X-Ray: Require radiologist report in addition to b-read. ? EKG: 12 Lead Resting EKG. Examiner signs off ? does not need to be read by a cardiologist. ? Spirometry: 3 best curves, < 5% variability ? Comprehensive vision: Near, Far, Depth, Peripheral, Color, Fields, Lateral/Vertical Phoria, Monocular, Binocular. With and without glasses, if applicable. ? Tonometry: if available ? Vital Signs/Body Ht/Body Wt: Temp, Pulse, Respiration, B/P. The Medical Provider must send ORIGINAL medical exam in the enclosed FedEx envelope for Quality Assurance within ONE WEEK OF COMPLETION. MSHA Checklist for Pre-Placement Exams The examining physician must discuss the medical history form (FOH 5) and any pre-existing conditions with patient. The examining physician must then address and document any positive medical history, physical findings, and significant abnormal lab values before exam is sent for QA. Ensure that all requested forms and test results are attached! Incomplete forms and missing test results ultimately delay the review process which can delay the hiring process. MSHA District Medical Provider Item ? ? Position Description ? ? Self-Addressed Envelope ? Medical Provider must mail COPY of exam to the patient. ? ? FedEx Envelope for ORIGINAL exam addressed to: ATTN: Caitlin Wilkinson Human Resources ? Medical Review Section 1100 Wilson Blvd, Rm 2121 Arlington, VA 22209 Ph 202-693-9759 Fx 202-693-9873 ? ? FOH 5 ? Health, History, and Physical Examination form ? ? FOH 6 ? Authorization for Disclosure ? ? FOH 9 and FOH 9(a) ? B-read Request/Tracking and B-Read of Chest X-ray ? Only required if Provider DOES NOT have Certified B-Reader ? ? CDC/NIOSH (M) 2.8 ? B-read Interpretation Form ? Provider must document results on this form if using own Certified B-Reader ? ? FOH 17 ? Audiogram History/Report ? ? FOH 22 ? OSHA Respirator Clearance (Part A mandatory, Part B filled out at discretion of examining physician) ? ? SF 78 (Part A completed by employee, Part C completed by Medical Provider) ? Certification of Medical Exam ? Audiogram Results ? Must test frequencies of 500, 1000, 2000, 3000, 4000, 6000, 8000 hertz. APPLICANTS ARE NOT PERMITTED TO WEAR HEARING AIDS DURING TESTING. Do not perform audiogram if ear(s) blocked (wax, infection, etc.). The hearing standard for applicants is as follows: < 40 dB at 500, 1000, 2000, 3000 Hz in each ear. If the applicant does not meet these standards, the Provider must schedule a repeat audiogram as soon as possible, but only after a 14-hr noise-free period. The Provider must notify the District Point of Contact when a repeat audiogram has been scheduled. ? Labwork: Chemistry ? Sodium, Potassium Chloride, Glucose, BUN, Creatinine, Calcium, Total Protein, Albumin, Total Bilirubin, Direct Bilirubin, Alkaline Phosphatase, ALT, GGT, LDH, CRP (LDL, HDL, Glucose, Total Cholesterol, Cholesterol/HDL ratio, Triglycerides). ? Urinalysis: PH, Protein Negative, Glucose Negative, Ketone Negative, Blood Negative, Nitrite Negative, Leukocyte Negative, Urobilinogen, Clarity. ? Hematology: WBC, RBC, HGB, HCT, MCV, MCH, MCHC, RDW-CV, Platelet, MPV, Differential: Neutrophils, Bands 0, Eosinophils, Basophils, Monocytes, Lymphocytes. ? B-read ? If you do not have a certified b-reader, please send original chest x-ray film and radiology report to: Dr. Jonathan Fish Diagnostic Radiology 33 Bonita Avenue Piedmont, CA 94611 ? Chest X-Ray: Require radiologist report in addition to b-read. ? EKG: 12 Lead Resting EKG. Examiner signs off ? does not need to be read by a cardiologist. ? Spirometry: 3 best curves, < 5% variability ? Comprehensive vision: Near, Far, Depth, Color, Peripheral, Fields, Lateral/Vertical Phoria, Monocular, Binocular. With and without glasses, if applicable. ? Tonometry: if available ? Vital Signs/Body Ht/Body Wt: Temp, Pulse, Respiration, B/P. The Medical Provider must send ORIGINAL medical exam in the enclosed FedEx envelope for Quality Assurance within 1-2 DAYS OF COMPLETION. MSHA Checklist for Mine Rescue Exams The examining physician must discuss the medical history form (SF 93) and any pre-existing conditions with patient. The examining physician must then address and document any positive medical history, physical findings, and significant abnormal lab values before exam is sent for QA. Ensure that all requested forms and test results are attached! Incomplete forms and missing test results ultimately delay the review which can restrict employees from regular duties. MSHA District Medical Provider Item ? ? Position Description ? ? Self-Addressed Envelope ? Medical Provider must mail COPY of exam to the patient. ? ? FedEx Envelope for ORIGINAL exam addressed to: ATTN: Caitlin Wilkinson Human Resources ? Medical Review Section 1100 Wilson Blvd, Rm 2121 Arlington, VA 22209 Ph 202-693-9759 Fx 202-693-9873 ? ? FOH 6 ? Authorization for Disclosure ? ? FOH 9 and FOH 9(a) ? B-read Request/Tracking and B-Read of Chest X-ray ? Only required if Provider DOES NOT have Certified B-Reader ? ? CDC/NIOSH (M) 2.8 ? B-read Interpretation Form ? Provider must document results on this form if using own Certified B-Reader ? ? FOH 17 ? Audiogram History/Report ? ? FOH 22 ? OSHA Respirator Clearance (Part A mandatory, Part B filled out at discretion of examining physician) ? ? SF 78 (Part A completed by employee, Part C completed by Medical Provider) ? Certification of Medical Exam ? ? SF 93 ? Report of Medical History ? ? MSHA 5000-3 form - Certification of Physical Quals for MR ? ? Physical Requirements for MR Team ? 30 CFR 49.7 ? ? Baseline Audio Summary ? Audiogram Results ? Must test frequencies of 500, 1000, 2000, 3000, 4000, 6000, 8000 hertz. IF PATIENT WEARS HEARING AIDS, AN AUDIOLOGIST MUST PERFORM THE TEST (with and without aids). Do not perform audiogram if ear(s) blocked (wax, infection, etc.). If baseline summary is missing from exam packet, please contact HQ immediately at the number listed above. The Medical Provider must determine if repeat is necessary and schedule within two weeks (after 14-hr noise-free period). The Provider must notify the District Point of Contact when a repeat audiogram has been scheduled. ? Labwork: Chemistry ? Sodium, Potassium Chloride, Glucose, BUN, Creatinine, Calcium, Total Protein, Albumin, Total Bilirubin, Direct Bilirubin, Alkaline Phosphatase, ALT, GGT, LDH, CRP (LDL, HDL, Glucose, Total Cholesterol, Cholesterol/HDL ratio, Triglycerides). ? Urinalysis: PH, Protein Negative, Glucose Negative, Ketone Negative, Blood Negative, Nitrite Negative, Leukocyte Negative, Urobilinogen, Clarity. ? Hematology: WBC, RBC, HGB, HCT, MCV, MCH, MCHC, RDW-CV, Platelet, MPV, Differential: Neutrophils, Bands 0, Eosinophils, Basophils, Monocytes, Lymphocytes. ? B-read ? If you do not have a certified b-reader, please send original chest x-ray film and radiology report to: Dr. Jonathan Fish Diagnostic Radiology 33 Bonita Avenue Piedmont, CA 94611 ? Chest X-Ray: Require radiologist report in addition to b-read. ? EKG: 12 Lead Resting EKG. Examiner signs off ? does not need to be read by a cardiologist. ? Spirometry: 3 best curves, < 5% variability ? Comprehensive vision: Near, Far, Depth, Color, Fields, Peripheral, Lateral/Vertical Phoria, Monocular, Binocular. With and without glasses, if applicable. ? Tonometry: if available ? Vital Signs/Body Ht/Body Wt: Temp, Pulse, Respiration, B/P. The Medical Provider must send ORIGINAL medical exam in the enclosed FedEx envelope for Quality Assurance within ONE WEEK OF COMPLETION. MSHA Checklist for Audiograms Ensure that all forms are filled out in their entirety and all requested test results are attached! MSHA District Medical Provider Item ? ? Self-Addressed Envelope ? Medical Provider must mail COPY of audiogram to the patient. ? ? Envelope for ORIGINAL results addressed to: ATTN: Caitlin Wilkinson Human Resources ? Medical Review Section 1100 Wilson Blvd, Rm 2121 Arlington, VA 22209 Ph (202) 693-9759 Fx (202) 693-9873 ? ? FOH 6 ? Authorization for Disclosure ? ? FOH 17 ? Audiogram History/Report ? ? Baseline Audio Summary ? Audiogram Results ? Must test frequencies of 500, 1000, 2000, 3000, 4000, 6000, 8000 hertz. IF PATIENT WEARS HEARING AIDS, AN AUDIOLOGIST MUST PERFORM THE TEST (with and without aids). Do not perform audiogram if ear(s) blocked (wax, infection, etc.). If baseline summary is missing from exam packet, please contact HQ immediately at the number listed above. The Medical Provider must determine if repeat is necessary and schedule within two weeks (after 14-hr noise-free period). The Provider must notify the District Point of Contact when a repeat audiogram has been scheduled. The Medical Provider must send the ORIGINAL audiogram results by regular mail in the enclosed envelope for Quality Assurance WITHIN 1-2 DAYS OF COMPLETION. PLEASE PROVIDE QUESTIONS BY 10/18/2007. NO PHONE CALLS WILL BE ACCEPTED. POC IS ALEISHA MOORE AT [email protected]

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