ML21153A398

Us Dept of Commerce, National Institute of Standards & Technology - NRC Physical Examination Form

ML21153A398
Person / Time
Site:	National Bureau of Standards Reactor
Issue date:	06/02/2021
From:	US Dept of Commerce, National Institute of Standards & Technology (NIST)
To:	Office of Nuclear Reactor Regulation
Shared Package
ML21153A395	List: ML21153A396 ML21153A397 ML21153A398
References
Download: ML21153A398 (6)

Text

Senior Reactor Operator or NRC Physical Examination Form Revision May 2021 Reactor Operator NAME DATE ORGANIZATION FACILITY DOCKET# PURPOSE OF EXAMINATION Reactor Operations & Engineering (610.01), NCNR, NIST 50-184 NRC-Issued SRO/RO License EXAMINING FACILITY OR EXAMINER, AND ADDRESS NIST HEALTH UNIT, BUILDING-101, ROOM. C-33. 100 BUREAU DRIVE GAITHERSBURG Md. 20899 I. MEDICAL HISTORY A. Check YES box or the NO box for items one through forty.

YES NO YES NO

1. Frequent or severe headaches 23. Painful or "trick" shoulder, elbow, hip,

2. Dizziness or fainting spells or knee

3. Diabetes 24. Foot pain

4. Thyroid disorder 25. Carpal Tunnel Syndrome

5. Cancer or blood disorder 26. Tremors or hands shaking

6. Skin problems 27. Numbness or tingling

7. Cataracts 28. Unsteadiness

8. Other eye trouble 29. Paralysis

9. Hearing loss or ringing in the ears 30. Epilepsy or seizures

10. Asthma, wheezing, or chronic cough 31. Other neurologic disorder

11. Shortness of breath 32. Depression or excessive worry

12. Tuberculosis 33. Excessive fatigue

13. Chest pain or tightness 34. Loss of memory or amnesia

14. Palpitations or irregular heart beat 35. Nervous condition which could impair

15. High blood pressure judgment or reliability

16. Low blood pressure 36. Claustrophobia

17. Heart trouble 37. Illegal drug use or drug addiction or

18. Peptic ulcer excessive alcohol consumption

19. Abdominal pain 38. Consideration of suicide

20. Inguinal hernia 39. Use corrective lenses to see

21. Back pain 40. Hearing impairment requiring use

22. Bone, joint, or other deformity of a hearing aid B. Check the YES box or the NO box for questions 1 through 9.

YES NO YES NO

1. Are you taking routine medication? 6. Have you ever been arrested or

2. Has your work ever been limited or detained for alcohol or drug related restricted for medical reasons? charges?

3. Have you ever been seen or evaluated by 7. Have you ever been a psychologist, psychiatrist, or counselor? hospitalized/admitted with mental health or substance abuse problems?

4. Have you been diagnosed with any 8. Have you been rejected for, or mental condition? discharge from employment for medical reasons? Have you been rejected for, ordischarged from the military for medicalreasons?

5. Have you ever had drug or alcohol problems? 9. Have you received, are receiving, or anticipate receiving compensation for a disability?

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Senior Reactor Operator or NRC Physical Examination Form Revision May 2021 Reactor Operator C. For any box checked YES in I.A or I.B, provide further details here. "Described mm/dd/yyyy."

D. Give a brief description of your present health.

E. I CERTIFY THAT THE FOREGOING INFORMATION SUPPLIED BY ME IS TRUE TO THE BEST OF MY KNOWLEDGE, AND AUTHORIZE THE RESPONSIBLE AUTHORITY TO USE THE INFORMATION ON THIS FORM IN THE EXERCISE OF ITS AUTHORITY OVER THE LICENSING OF OPERATORS .

SIGNATURE DATE Page 2 of 6

Senior Reactor Operator or NRC Physical Examination Form Revision May 2021 Reactor Operator II. MEDICAL EXAMINATION A. GENERAL Project Task Number 6101110-000 Organizational Code 30-61-0610-01-00-00-00 HEIGHT WEIGHT PULSE BLOOD PRESSURE LYING SITTING STANDING B. CLINICAL NORMAL YES NO NOTES

1. Vital signs

2. Head, face, neck

3. Eyes, general

4. Ears, general

5. Ear drums

6. Nose and sinuses

7. Mouth and throat

8. Lungs and chest

9. Heart

10. Vascular system

11. Abdomen and viscera

12. Endocrine system

13. G-U system

14. Upper extremities, strength and range of motion

15. Feet

16. Lower extremities, strength, and range of motion

17. Spine, other musculoskeletal

18. Skin, lymphatics

19. Neurologic

20. Psychiatric, specify any personality deviation

21. EKG/ECG

22. Bloodwork

23. Urinalysis

24. Pulmonary Function Test / Spirometry ADDITIONAL CLINICAL NOTES Referrals for further evaluation or testing Page 3 of 6

Senior Reactor Operator or NRC Physical Examination Form Revision May 2021 Reactor Operator C. VISION AND HEARING

1. Vision DESCRIPTION LEFT RIGHT METHOD USED Distant Visual Acuity Uncorrected 20/ 20/

Distant Visual Acuity Corrected 20/ 20/

Near Visual Acuity Uncorrected 20/ 20/

Near Visual Acuity Corrected 20/ 20/

Peripheral Vision Degrees Stereovision PASS FAIL Color Vision PASS FAIL Notes

2. Hearing FREQUENCY LEFT RIGHT METHOD USED 500 Hz 1000 Hz 2000 Hz 3000 Hz Notes Page 4 of 6

Senior Reactor Operator or NRC Physical Examination Form Revision May 2021 Reactor Operator D. SPECIFIC RESULTS AND PHYSICIANS RECOMMENDATIONS YES NO

1. Was there any condition, habit or practice which might result in sudden or unexpected incapacitation?

YES NO

2. Was there any mental or physical disability which might cause impaired judgement or motor coordination?

3. Based on the results of the examination and medical history, using the criteria contained in ANSI/ANS 15.4 - 2016 and ANSI/ANS 3.4 - 2013 Section 5.7, I havedetermined that the applicants physical condition and general health are such that (circle all that apply)

A. THERE ARE NO RESTRICTIONS OR DISQUALIFYING CONDITIONS B. THE FOLLOWING RESTRICTIONS OR WAIVERS APPLY

1. CORRECTIVE LENSES SHALL BE WORN WHEN PERFORMING LICENSE DUTIES

2. HEARING AID SHALL BE WORN WHEN PERFORMING LICENSE DUTIES. THIS DOES NOT APPLY TO CONDITIONS THAT REQUIRE PROTECTION IN HIGH NOISE AREAS

3. SHALL TAKE THE FOLLOWING MEDICATIONS AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATION

a. d.

b. e.

c. f.

4. OTHER C. A DISQUALIFYING CONDITION EXISTS AS NOTED BELOW NAME OF PHYSICIAN STATE IN WHICH LICENSE NUMBER LICENSED SIGNATURE DATE Page 5 of 6

Senior Reactor Operator or NRC Physical Examination Form Revision May 2021 Reactor Operator AUTHORIZATION TO RELEASE HEALTH INFORMATION I AUTHORIZE THE NIST HEALTH UNIT TO RELEASE MY PRIVATE / PERSONAL HEALTH INFORMATION TO:

(NAME, ADDRESS, PHONE / FAX NUMBER)

Chief of Reactor Operations NIST Center for Neutron Research 100 Bureau Drive Bldg. 235/A137 Mail Stop 6101 Gaithersburg Md 20899-6101 (301) 975-6262 (Phone)

Type of Information to be released:

History and physical exams Consultations and Evaluations Progress Notes Radiology, laboratory, pathology, EKG and other diagnostic reports Operative reports Psychological reports Medical opinions regarding accommodations, fitness for duty, light duty assignments Emergency medicine reports NRC Physical Examination Form Other: ___________________________

Date or time period for information selected above The purpose of this release:

At the request of the patient To make an assessment regarding work related accommodations To determine employee's fitness for duty To determine an appropriate light duty assignment, if available My Rights and Responsibilities

> This authorization is voluntary

> Patients may revoke this authorization at any time by submitting written notice to the Medical Officer, PA-C The revocation will take effect when Imani Patterson, PA-C receives it, unless the request has already been released. Revocations cannot reverse any releases that have already occurred.

> Patients are entitled to receive a copy of this authorization if requested

> The NIST Health Unit has no control over, responsibility for, or liability related to any private health information once released to another entity at patient request Expiration of authorization:

Unless otherwise revoked , this Authorization expires (insert applicable date)

If no date indicated, Authorization expires 12 months after date of signing.

SIGNATURE DATE PRINT NAME TIME AM / PM RECEIVED BY: DATE / TIME DATE PROCESSED: TIME PROCESSED:

PROCESSED BY:

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