Document
Special Agent Medical (Preplacement/Incumbent
ICR 202610-1140-022 · OMB 1140-0056 · Object 174215500.
Document Viewer [pdf]
Status: Original and derived artifacts are available for this document.
Download: pdf
Loading document viewer…
Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | Special Agent Medical (Preplacement/Incumbent |
| Subject | Special Agent Medical (Preplacement/Incumbent |
| Keywords | ATF For 2300.10 Special Agent Medical (Preplacement/Incumbent |
| Author | ATF |
| Last Modified By | Adobe InDesign CC 13.1 (Windows) |
| File Modified | 2020-01-23 |
| File Created | 2019-12-12 |
| Conversion State | complete |
Extracted Text
OMB No. 1140-0056 (xx/xx/xxxx) U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives Special Agent Medical (Preplacement/Incumbent) Part I - Demographic Data (To be completed by special agent/applicant) 2. Date of Birth 3. Date of Testing 4. Social Security Number 1. Name (Please print or type) 5. Sex Male 6. Home Address 7. Home Telephone Number Female 8. Work Telephone Number 9. Field Office 10. Field Office Mailing Address 11. Personal Telephone Number 12. Current Employer 13. Current Occupation 14. How Long in Current Position? (Years/months) Part II - Medical History (To be completed by special agent/applicant. Please check each item yes or no. If yes, please explain) 15. Have you been refused employment or been unable to hold a job or stay in school due to any medical condition? Yes No Yes No AF T 16. Have you ever been treated for any mental condition? 17. Have you ever been denied life or health insurance? (If yes, state reason and provide details.) 18. Have you had, or been advised to have, any operation? Yes Yes No No 19. Have you ever been a patient in any type of hospital? (If yes, specify when, where and give details.) Yes No R 20. Have you ever had any illness or injury other than those already noted? (including learning disabilities and Attention Deficit Disorder (ADD), etc. If Yes No yes, specify when, where and give details.) D 21. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illness? (If yes, Yes No give complete address of doctor, hospital, clinic, and give details.) 22. Females Only: Are you currently pregnant? (If yes, provide trimester. This question relates only to issue of the safe participation in training.) Yes No 23. Have you ever been rejected or discharged from military service because of physical, mental condition, or for other reasons? (If yes, give date, reason Yes No and type of discharge: whether honorable, other than honorable, for unfitness or unsuitability.) 24. Have you ever received, is there pending, or have you applied for pension or compensation for existing disability? (If yes, specify what kind, granted by whom, what amount, when, and why.) Yes No 25. Have you had or are you currently experiencing any of the following? (If yes, please explain) Blurred vision? Yes No Color blindness? Yes No Glaucoma? Yes No 26. Do You? (If yes, please explain) Wear glasses or contact lenses? Yes Have cataracts? Yes No No Have you ever been diagnosed with any eye disease? (If yes, please explain) Yes No ATF Form 2300.10 Revised ( ) Have you had any type of eye surgery (i.e., RK, PRK, cataracts, etc.)? (If yes, please explain what specific surgery was performed and the date of surgery.) Yes No R AF T 27. Have You Experienced Any of the Following? (If yes, please explain below) Difficulty hearing Yes No Loud, constant noise or music within the last 14 hours Dizziness Yes No Do you wear a hearing aid? Loud, impact noise in past 14 hours Yes No Do you use hearing protective equipment? Are you in a hearing conservation program? Yes No Ankles or feet swelling Chest pains Yes No Palpitations (rapid or skipped heart beat) Leg pains Yes No Past history or diagnosis of heart disease Heart murmur Yes No Heart attack or stroke Coronary bypass surgery/other heart surgery Yes No Abnormal treadmill Abnormal EKG (Resting) Yes No Cold hands or feet when others are comfortable in same Numbness in feet/hands Yes No room Phlebitis or blood clots Yes No High blood pressure Bronchitis, tuberculosis Yes No Problems with breathing, wheezing, persistent cough, Asthma Yes No /shortness of breath Heat/sun stroke Yes No Past history or diagnosis of lung disease or surgery Thyroid disease Yes No Diabetes Blood disorder Yes No Pituitary gland problem Back pain Yes No Anemia Joint pain or swelling Yes No Back surgery Lack of coordination Yes No Tingling in head/hands/legs Tremors/shakiness Yes No Epilepsy (seizure) Persistent stomach/abdominal pain Yes No Loss of sensation Vomiting blood Yes No Stomach ulcers Trouble walking Yes No Trouble using hip/knee/shoulder Loss of strength/muscle weakness Yes No Loss of joint/limb movement Arthritis Yes No Any limb or finger amputations Skin problems, urticaria Yes No Gout Kidney disease Yes No Urinary pain/infection/bleeding Are you left handed? Yes No Localized weakness/numbness Persistent diarrhea/constipation Yes No Are you right handed? Liver disease Yes No Blood in stool Gall bladder problems Yes No Hepatitis Psychiatric/psychologic consult Yes No Hernia Periods of nervousness Yes No Feelings of depression Ringing or buzzing in ears Yes No Fainting Syncope D Explanation: 28. Your Current Physical Activity or Exercise Program Intensity 29. Frequency of 30. Duration of Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No 31. Activities Days Per Week Minutes Per Session Low Moderate High 32. Medications (List all medications (prescription and non-prescription) you are currently taking with dosage, frequency and reason.) 33. Allergies (Please check where applicable) None Dust or molds (Specify) Drugs (Specify) Animals (Specify) Pollens (Specify) Food (Specify) Other (Specify) 34. Have You Ever Smoked? Yes No Part III - Social History (To be completed by special agent/applicant) 35. If Yes, When? 36. Type Cigarette Currently Past (Number of years since you quit) 37. How Many Do or Did You Smoke Per Day? Pipe Cigar 38. For How Many Years? ATF Form 2300.10 Revised ( ) 39. What is Your Average Alcohol Consumption in a Week? (1 drink = 12 oz. beer, 1 glass of wine, 1.5 oz. liquor) Drinks 40. How Often Do You Drink Alcohol? Weekdays Weekends Both I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals, or clinics mentioned on these forms to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. I authorize the release of all medical information to the Federal Occupational Health/Law Enforcement Medical Program and the Bureau of Alcohol, Tobacco, Firearms and Explosives point of contact. Client’s Signature Date Witness’s Signature Date Part IV - To Be Completed By Clinic (Please print) Address/Location of Clinic Name of Clinic RN Telephone Number (Include area code) MD/DO AF T Part V - To Be Completed By Health Care Provider Disclaimer: This examination does not substitute for a periodic health examination conducted by your private provider. It is being conducted for occupational purposes. 1. Preplacement Service: Lab Components Fasting Blood Comprehensive Metabolic Panel CBC (included Diff/Plat) D R Labs (blood & urine) Cholesterol Total Glucose Blood Lead & ZPP Triglycerides Urea Nitrogen (BUN) Height, weight, vitals HDL - cholesterol Creatinine LDL - cholesterol BUN/Creatinine EKG (12 lead with interpretation) PPD Mantoux (TB skin test) Chol/HDL Sodium Audiometry (500 Hz - 8000 Hz) Bilirubin Potassium Vision screening (Near & Far; Transferase Chloride Corrected & Uncorrected) GGT Protein, Total Color vision (14 plate Ishihara) LDH, Total Globulin Peripheral vision (nasal & temporal) Alanine Transminase Albumin/Globulin Ratio Tonometry Alkaline Phosphatase Depth Perception (seconds of arc) AST (SGOT) General Physical Exam General Medical history Attach copies of all test results Head, Face Neck (thyroid) Scalp Nose/Sinuses Mouth/Throat Pupils Equal/Reactive Ocular Motility Ophthalmoscopic Findings 4. Intraocular Pressure Type of Test: Type of Tester Type Of Test Titmus Ishihara Plate Other (Specify) 5. Peripheral Vision (Require numerical values) mm/hg Left Puff mm/hg Shiotz Depth Perception (Require documentation of:) # Correct Color Appearance Specific Gravity Glucose Ketones Occult Blood Protein Nitrite Leukocyte Esterase Microscopic if indicated Part VI - Diagnosis and Physical Findings (To be completed by Health Care Provider) 3. Color Vision (Require documentation of:) 2. Head and Neck Abnormal Right White blood cell count Red blood cell count Hemaglobin Hematocrit MCV MCH RDW Platelet Count Neutrophils Lymphocytes Absolutes Monocytes Monocytes Absolute Eosinophils Eosinophils Absolute Basophils Basophils Urinalysis of Total Tested Arc Seconds of Arc Shepard - Fry % Nasal Nasal Total Total ATF Form 2300.10 Revised ( ) 6. Uncorrected Vision (Snellen Units) Right 20/ Right 20/ 8. Comment on Heent Abnormalities: 9. Frequency 7. Corrected Vision (Snellen Units) Right 20/ Right 20/ Left 20/ Left 20/ 500 Hz Part VII - Audiology (To be completed by Health Care Provider) 1000 Hz 2000 Hz 3000 Hz 4000 Hz Baseline Annual Left 20/ Left 20/ 6000 Hz 8000 Hz Right Ear Left Ear 10. Audiogram: Calibration Method: Termination (Attach current and baseline audiogram) Oscar Biological Change Date No Change Right Ear Normal Abnormal Left Ear Canal/External Ear: Normal Abnormal Canal/External Ear: Normal Abnormal Tympanic Membrane: Normal Abnormal Tympanic Membrane: Normal Abnormal 11. Vital Signs: Height AF T Comments: Weight Blood Pressure mm/hg (sitting) Date Read Degrees of Induration (sitting) Temperature (If indicated) Date of Last Chest X-ray D 12. Tuberculosis Date Administered R Comments: Pulse Comments (Chest X-rays, TB treatment/dates): 13. Cardio/Pulmonary: EKG (Attach with interpretation): Normal Abnormal Lungs/Chest (includes breast): Normal Abnormal Heart (murmur, palpitations, ectopic beats): Vascular (varicosities): Normal Abnormal Normal Abnormal Comments: 14. Pulmonary Function Testing (Attach copy): % Predicted FVC % Predicted FEV1 % Predicted FEV1/FVC % Predicted FEF 25 - 75 Comments: ATF Form 2300.10 Revised ( ) Part VIII - Diagnosis and Physical Findings (To be completed by Health Care Provider) 15. Musculoskeletal Upper Extremities (strength): Normal Abnormal Lower Extremities (range of motion): Normal Abnormal Flexibility Normal Abnormal Upper Extremities (range of motion): Normal Abnormal Lower Extremities (strength): Normal Abnormal Feet Spine Normal Abnormal Deep Tendon Reflexes Normal Abnormal Normal Other Neurological Normal Abnormal Abnormal 16. Can Applicant Participate in the Following: Yes Vigorous Aerobic Exercise Program 3 Hr/Wk (minimum) Pull Ups Yes No Yes Sit Ups No No Push Ups Yes No One and One Half Mile (1.5) Time Run Yes No Comments: 17. Is Applicant Capable of the Following: Yes Yes Yes Yes No Squat and rise without holding on to any object. Maintain squatting and kneeling for up to 45 seconds repeatedly. No Kneel on one knee with arms extended in front of body at eye level for seven (7) seconds. No Assume a one and two-knee kneeling position within two (2) seconds and be able to rise without assistance. Be able to repeat twice. No Maintain a kneeing position for 2 - 3 minutes repeatedly. AF T Please Comment on “Cannot Participate” Responses: Abnormal Mental/Emotional Affect (describe if abnormal) Normal Abnormal G -U System Normal Abnormal Abdomen, Viscera Normal Abnormal Skin (scar/unique markings) Normal Abnormal Lymphatic Normal Abnormal Other D Comments: R Normal Part IX - Education and Referral (To be completed by the Health Care Provider) 18. Check the Topics Discussed During the Diagnosis Work-up or Physical Exam: Lipids Hypentension Exercise Obesity Smoking Cessation Alcohol Use Hearing Protection Vision Referral Other Personal Protective Equipment Job Stressors Referral(s) Immunizations Part X - Examining Physician’s Summary of Significant Findings With Recommendations Note: Please do not provide any official statement (oral or written) concerning the applicant’s fitness or capability to perform the duties of any occupation. The Agency’s Medical Review Officer will provide this statement. Examining Physician’s Name (Print or type) Examining Physician’s Signature Date ATF Form 2300.10 Revised ( ) When Exam is Complete, UPS Within Two Days To: Program Support Center U.S. Department of Health and Human Services 299 Main Street, Suite 446 Salt Lake City, UT 84111 ATF Use Only Action Taken: Hired or Retained Non-selected For Appointment, or Eligibility Objected to Action Taken to Separate Human Resources Officer’s Signature Human Resources Officer’s Name (Print or type) Date Privacy Act Information AF T Executive Order, 9830 and 5 CFR 339.301 authorizes collection of this information. The primary use of this information is to determine medical suitability to qualify for a position that has specific medical standards, physical requirements, or is covered by a medical evaluation program established under these regulations. Furnishing this information is mandatory because such information is part of the basic qualifications for the position. If this information were not provided, the applicant would fail to meet the qualifications for the position. Additional disclosures of this information may be: To the Department of Labor when processing a claim for compensation regarding a job connected injury or illness; to Federal Life Insurance or Health Benefits carriers regarding a claim; to another Federal agency; to a court, or a party in litigation before a court or in an administrative proceeding when the government is a party or when the agency deems it to be relevant and necessary to the litigation; to a Federal, State, or local law enforcement agency when such agency becomes aware of a violation or possible violation of civil or criminal law; to a Federal agency when conducting an investigation for employment or security reasons; to the General Services Administration in connection with responsibilities for records management. Paperwork Reduction Act Notice R This information collection request is in accordance with The Paperwork Reduction Act of 1995. The purpose of this information is to determine whether or not an applicant is actually qualified for the position. The information will be initially used to make a recommendation on either hiring or not hiring an applicant or retaining an individual in a special agent position. D The estimated average burden associated with this collection of information is 45 minutes per respondent or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to Reports Management Officer, Document Services Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. ATF Form 2300.10 Revised ( )