MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE ...

[Pages:3]MEDICAL RECORD

DATE

CHRONOLOGICAL RECORD OF MEDICAL CARE

PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal or regulatory investigations or prosecutions. The Social Security Number, authorized by Public Law 93-579 Section 7 (b) and Executive Order 9397, is used as a unique identifier to distinguish between employees with the same names and birth dates and to ensure that each individual's record in the system is complete and accurate and the information is properly attributed.

Employee info:

Occupation

Agency

Code

Work Location

Work Supervisor

Duty tel. #

Visit for: BASELINE EXPLOSIVES VEHICLE OPERATORS 720 CERTIFICATION EXAMINATION Medical History

Comments on Medical History:

MEDICAL FACILITY

DEPARTMENT/SERVICE

EMPLOYEE'S IDENTIFICATION: LAST NAME, FIRST NAME, MIDDLE INITIAL

GENDER (M/F)

DATE OF BIRTH (DD-MMM-YYYY)

STATUS (AD / RESERVE / CIV) SERVICE

ID#

RANK/GRADE

Page 1 of 3

RECORDS MAINTAINED AT

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 11/2010) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

Do not re-use this form after 4/4/2022

MEDICAL RECORD

DATE

Vital Signs

Blood pressure:

Pulse:

CHRONOLOGICAL RECORD OF MEDICAL CARE

Respiratory rate:

Temperature:

Height:

Weight:

Physical Examination

Comments on Physical Exam findings, if applicable:

MEDICAL FACILITY

DEPARTMENT/SERVICE

EMPLOYEE'S IDENTIFICATION: LAST NAME, FIRST NAME, MIDDLE INITIAL

GENDER (M/F)

DATE OF BIRTH (DD-MMM-YYYY)

STATUS (AD / RESERVE / CIV) SERVICE

ID#

RANK/GRADE

Page 2 of 3

RECORDS MAINTAINED AT

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 11/2010) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

Do not re-use this form after 4/4/2022

MEDICAL RECORD

DATE

CHRONOLOGICAL RECORD OF MEDICAL CARE

Assessment

Certification Examinations EXPLOSIVES VEHICLE OPERATORS (720)

Qualified

Not Qualified

Disposition and Follow-up

Released from Occupational Health Clinic

Follow-up with PCM for

Return for follow-ups for: EXPLOSIVES VEHICLE OPERATORS Other disposition:

2 years .

Discussed results of this visit with employee

Complete OPNAV 8020/6 (mil only)

Complete Medical Examination Report (MER), Form MCSA-5875 (both mil & civ)

Complete Medical Examiner's Certificate (MEC), Form MCSA-5876 (civ only)

Complete CMV Driver Medical Examination Results Form, MCSA-5850 (civ only)

For certifications requiring OPNAV 8020/6, Medically Qualified only when:

Wearing corrective lenses

Wearing hearing aid(s)

Driving within an exempt intra-city zone (49 CFR 391.62)

Accompanied by a Skill Performance Evaluation Certificate (SPE)

Qualified by operation of 49 CFR 391.64

Accompanied by a waiver/exemption:

INTRASTATE ONLY Yes No

CDL: Yes No

Limitations and comments:

Pending

Healthcare Professional Signature & Stamp: _________________________________________________ Date:____________________

MEDICAL FACILITY

DEPARTMENT/SERVICE

EMPLOYEE'S IDENTIFICATION: LAST NAME, FIRST NAME, MIDDLE INITIAL

GENDER (M/F)

DATE OF BIRTH (DD-MMM-YYYY)

STATUS (AD / RESERVE / CIV) SERVICE

ID#

RANK/GRADE

Page 3 of 3

RECORDS MAINTAINED AT

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 11/2010) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

Do not re-use this form after 4/4/2022

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