9

Examples of Pre-deployment Screening Tools Used by Selected Emergency Response Units

Basic Evaluation

Interim Guidance for Pre-exposure Medical Screening of Workers Deployed for Hurricane Disaster Work 

http://www.cdc.gov/niosh/topics/emres/preexposure.html

This document provides interim guidance on medical screening for workers before deployment to disaster

response activities.

ROTC

http://college.vfmac.edu/LinkClick.aspx?fileticket=mlI8NoG3Z5c%3d&tabid=180

Very basic set of questions for a ROTC program. 

Center for Domestic Preparedness Responder Screening Tool 

http://www.emd.wa.gov/training/documents/Medical_Screening_FormCDP.pdf

Tool is used for responders under consideration for attendance at the Center for Domestic Preparedness, 

WMD Technical Emergency Response Training Course (TERT), WMD HAZMAT Technician Training Course (HT), 

WMD Hands-On Training Course (HOT), WMD Emergency Medical Services Course (EMS), WMD Emergency 

Responder Hazardous Materials Technician Course (ER HM), Agricultural Emergency Response Training, and 

the MCATI courses (CSM, HEC, BASIC, and PD).

Department of Defense Deployment Health Clinical Center - Form DD 2795 

http://www.pdhealth.mil/dcs/pre_deploy.asp

The Pre-deployment Health Assessment Form (DD 2795) is a required form that allows military personnel to 

record information about their general health and share any concerns they have before deployment. It also 

helps healthcare providers identify issues and provide medical care before, during, and after deployment.

• DD 2795 is mandatory for deploying military personnel from every service, including reserve

component personnel

• DD 2795 is to be completed and validated within the 30 days before deployment.

Enhanced Evaluation

Coast Guard Auxiliary Air Crew Screening Form

http://forms.cgaux.org/archive/a7042f.pdf

It may also be considered a Basic form, but it does go into disqualifying specific medical conditions, it has 

been placed in this section as an example of an Enhanced Form.

CDC Emergency Response Team Medical Clearance Guidelines

(Hard copy is below)
10

This document was formulated to establish general guidelines for use in the medical evaluation and the

fitness-for-duty clearance of applicants who volunteer to participate on the CDC-wide Emergency Response 

Team. It can represent an “enhanced” set of screening criteria used for those with responder duties that 

put them at moderate risk of injury and illness.

CDC Responder Readiness Medical Clearance

Name: Date: 

Social Security Number: 

The information you provide in this clearance exam is private and confidential. 

Past Medical and Surgical History (List any past or current medical complaints, diseases, symptoms, surgeries, 

procedures or other conditions) 

Date Condition Current Status 

Family History (List any medical conditions of blood relatives including high blood pressure, heart or kidney disease, 

diabetes, cancer, alcoholism, psychiatric illness or others) 

Social History

Do you use tobacco in any form? No Yes 

Do you drink alcohol in any form? No Yes 

Do you use illegal drugs or misuse other drugs? No Yes 

Explain any “yes” answers. 
11

Assessment of Physical Activity Level (Describe type, amount and frequency of physical activity that you 

complete on a regular basis.) 

Current Medications (Include prescription, over-the-counter, vitamins, supplements, herbals, others) 

Allergies (List and describe medication, food, insect or other allergic reaction or adverse event) 
12

Name: Date: 

Immunization History (Give month and year when immunization(s) last completed if known) 

Tetanus/Diphtheria 

Hepatitis A 

Hepatitis B 

Measles/Mumps/Rubella 

Varicella (if unknown, must titer) 

Anthrax 

Smallpox 

TB Skin Testing 

Review of Symptoms in Major Body Systems HAVE YOU EVER HAD:

YES NO YES NO

1. Frequent or severe headaches? 26. Kidney or prostate disease? 

2. Dizzy spells, fainting or blackouts? 27. Diabetes? 

3. Epilepsy or seizures? 28. Thyroid disease? 

4. Eye trouble or vision problems? 29. Other endocrine disease? 

5. Ear problems or difficulty hearing? 30. Heavy menstrual bleeding? 

6. Hay fever or other allergies? 31. Anemia/hematological disorder? 

7. Dental problems? 32. Easy bruising or bleeding? 

8. Other ear, nose or throat problems? 33. Blood clots? 

9. Wheezing or asthma? 34. Arthritis/joint pains/swelling? 

10. Shortness of breath on exertion? 35. Other connective tissue disease? 

11. Chronic cough? 36. Joint or bone deformity/fracture? 

12. Coughing up blood? 37. Back pain; wear a back brace? 

13. Tuberculosis or (+) Tb skin test? 38. Difficulty walking? 
13

YES NO YES NO

14. Pain or pressure in your chest? 39. Eczema or atopic dermatitis? 

15. Palpitations or pounding heart? 40. Other rashes? 

16. Heart murmur? 41. Any other skin diseases? 

17. Other heart problems? 42. Cancer? 

18. High or low blood pressure? 43. Any immune system disorder? 

19. Frequent indigestion/heartburn? 44. Chronic steroid treatment? 

20. Stomach or intestinal problems? 45. Other immunosuppressive drugs? 

21. Hepatitis or liver disease? 46. Nerve injury or paralysis? 

22. Rupture or hernia? 47. A sleep disorder? 

23. Rectal bleeding or discharge? 48. Easy fatigability? 

24. Frequent urination? 49. Depression or crying spells? 

25. Kidney stones? 50. Other psychiatric problems? 

Give details of any “yes” answers above and comment on the current status of symptoms. 

List and describe any other medical problem, symptom, or concern not addressed above. 
14

For women only: Are you currently pregnant? No Yes Date of last menstrual period: 

Name: Date: 

Please read and sign the following statement. If you feel you need additional information or have any 

questions regarding the medical risks of deployment or questions regarding the medical clearance 

process, please ask the CDC Occupational Health Clinic medical staff. 

Deployment on a CDC/ATSDR emergency response team could involve physical and emotional 

stressors and hazards, including but not limited to:

• rapid deployment to any location upon short notice

• deployment lengths lasting weeks to months

• separation from family and friends

• personal security issues

• sleep deprivation, time zone changes, and irregular sleep schedules

• irregular quality, availability, and variety of meals

• exposures to extremes of climate and altitude

• limited availability of immediate medical care

• lack of refrigeration or electricity for medications, medical supplies, or equipment

• increased physical demands related to prolonged standing, walking, or exertion

• routine use of personal protective equipment such as respirators and protective clothing

• possible exposure to infectious organisms, chemical, or radiologic agents

• risk related to allergy, adverse events or side effects from medications, vaccines, or other required

pharmaceutical interventions

• for pregnant women, possible risk to a developing fetus

I have read the above medical questionnaire and statements. I have answered all questions accurately 

and to the best of my knowledge. I realize that further information or testing may be needed from 

my private physician or other sources to clarify my fitness for this duty. I know of no condition which 

would impair my ability to function fully on a CDC emergency response team now or for the following 

two years. 

Signature Date 
15

You may STOP here. The clinic staff and physician will complete the remainder of this form

Name: Date:

TO BE COMPLETED BY PHYSICIAN:

Height Weight Pulse BP Distant vision: 

R 20/ 

L 20/ 

Corrected? Y N

CLINICAL 

EVALUATION

Check each 

item as 

indicated. 

Enter 

'NE’ if not 

evaluated

Normal Abnormal Notes or Other Comments

1. Skin

2. Head and neck (thyroid)

3. Ear, nose, and throat

4. Lymph nodes

5. Eyes (include fundoscopic)

6. Lungs

7. Breast

8. Heart

9. Abdomen

10. Genitalia (if indicated)

11. Rectal exam (if indicated)

12. Vascular system

13. Extremities and spine

14. Neurological

15. Psychiatric (specify any significant cognitive, mood or behavioral observations)
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Comprehensive Evaluation

NFPA 1582 Chapter 6 Medical Evaluations of Candidates

http://www.nfpa.org/aboutthecodes/list_of_codes_and_standards.asp?cookie%5Ftest=1 

http://www.cortlandcountyfire.org/NFPA%201582.pdf

This document provides a detailed list of the medical conditions that could impact the ability of a fireman to 

safely perform essential job tasks. It can be used as an example of the type of “comprehensive” questions 

that could be used for a screening exam for those responders who face serious hazards and risks when 

responding to emergencies, such as those faced by firefighters.

USCG Medical Manual CIM 6000.1C

http://www.uscg.mil/directives/listing_cim.asp?id=6000-6999

This is a very comprehensive program aimed to cover all operations of USCG Personnel, ranging from air

crewmen and marine vessel inspectors to pollution and emergency responders. There is a basic form that

all personnel fill out, and then, for each specific hazards to which the member may be exposed, there is a 

form geared specifically for those hazards (e.g., asbestos, benzene, noise). 

Department of Defense Deployment Health Clinical Center - Form DD 2795

http://www.pdhealth.mil/dcs/pre_deploy.asp

The Pre-deployment Health Assessment Form (DD 2795) is a required form that allows military personnel to 

record information about their general health and share any concerns they have before deployment. It also 

helps healthcare providers identify issues and provide medical care before, during, and after deployment.

• DD 2795 is mandatory for deploying military personnel from every Service, including Reserve

Component personnel, and

• DD 2795 is to be completed and validated within the 30 days prior to deployment.

American Red Cross

These documents are used by the American Red Cross to assess their volunteer’s health status before 

deployment. (Not available online; hard copies are attached below.)

• Health Status Record: Self assessment of physical abilities, medical issues, and medications filled 

out by the volunteer and updated yearly

• Health Status Record Review Summary Sheet: Administrative assessment completed by the RN or

MD from the unit after reviewing the Health Status Record from the volunteer

• Pre-assignment Health Questionnaire: Checklist filled out by the unit deploying the volunteer 

including several health questions asked to the volunteer immediately prior to deployment to 

assess if there has been a change in health status since the completion of the Health Status Record

• Physical Capacity Grid: Matrix that lists the potential disaster deployment roles and the physical 

requirements for each
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Health Status Record

CONFIDENTIAL

To be completed and signed by the individual. Please print all information

New Annual Update Change in Health Status

If this is an Annual Update, is there a change in:

Health Status Address Phone No. E-mail Address Contact Information

Name: DSHR # 

Last First MI

Address: 

Phone: 

E-mail Address: 

Emergency Contact: 

Unit of Affiliation: 

Street City State ZIP 

Home Cell Work

Name Phone Relationship

Chapter Name Phone Chapter Code

Group/Activity/Position: 

First Second Third

Mark Yes if you are able and No if not able and explain any limitations under “Limitation Explanations”

below (all accommodations must be requested in writing with supporting medical documentation):

yes no Lift and carry 20 lbs multiple times per shift yes no Speak clearly on phone and in person

yes no Lift and carry 50 lbs multiple times per shift yes no Read small print for extended periods

yes no Stand for two-hour periods yes no Work for long periods on a computer

yes no Sit for two-hour periods yes no Climb two or more flights of stairs

yes no Walk on uneven terrain yes no Drive in daytime and at night

yes no Walk two miles during a shift yes no Work/live in areas with mold/mildew

yes no Bend or stoop multiple times during a shift yes no Work/live in areas with smoke/poor air

yes no Crawl on floor or ground yes no Work/live with little or no privacy

yes no Work outdoors in inclement weather yes no Sleep on the floor or a cot

yes no Work in extreme heat and/or humidity yes no Travel by any type of transportation

yes no Work in extreme cold yes no Work 12 hr shifts/nights/weekends

yes no Able to step up/down 18 inches yes no Work productively during change/stress

yes no Spend hours writing

Mark Below Yes if Required or No if Not Required

yes no Electricity for medical devices/meds yes no Assistance with health monitoring

yes no Special food or timing of meals yes no Air conditioning for health reasons

yes no Access to specialized medical care

Limitation(s) Explanations:

Date of last Tetanus shot (Within 10 years is considered up to date):

Height: Weight: DOB:

Allergies (food, medication, insect, dust, latex, etc.) What happens? What do you do? 

Explanations:
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In the last 12 months, have you been diagnosed with/continued treatment for any of the following?

yes no Heart attack/heart disease yes no Bleeding disorders/anticoagulation therapy

yes no High blood pressure yes no Stroke/CVA/TIA

yes no Migraines/frequent headaches yes no Mental Health (Anxiety/PTSD/Bipolar)

yes no Skin problems/breaks in skin/lesions yes no Seizures/nervous system/neurological

yes no Stomach/intestine/hernia yes no Sleep apnea/sleep disorders

yes no Urinary problems yes no Problems walking, moving

yes no Asthma/COPD/emphysema yes no Back/joint/bone problems

yes no Vision problems (Not corrected) yes no Immune system problems

yes no Hearing problems/hearing aids yes no Infectious disease

yes no Diabetes Other:

Explain ‘yes’ items above:

Any ER visits, hospitalizations, surgeries or ongoing therapy during the last 12 months? yes no

If yes, explain and include dates:

Please list all prescription and over-the-counter medications, and reason for taking: 

MEDICATIONS HOW OFTEN REASON FOR TAKING

List all medical equipment or assistive devices used (crutches, canes, nebulizer, CPAP, oxygen, 

braces (arm/leg), wheelchair, service animals, etc.):

I have reviewed the physical requirements for my group and activity in Connection 2006-028, Deploying a Healthy

Workforce and the DSHR System Handbook (with addendums) with my unit of affiliation. I understand the 

physical requirements for being a disaster worker and hereby state that I am able to fulfill those requirements. I 

understand that if my health status changes, I am responsible for updating this form immediately and submitting to 

my unit of affiliation. 

I understand that while health insurance is NOT required, I will be financially responsible for my health care 

expenses.

In signing below, I give permission for the Red Cross Staff Health Reviewer to contact my health care provider for 

information concerning my current health status. I will be notified before contact with my health care provider is 

made. I understand that refusal to sign may limit deployment. 

My typed signature/date is verification that information on this form is correct. Please sign form if faxing.

Signature of DSHR Member: Date: 

Signature of Health Reviewer: Date: 

Codes-Hardship/Restriction:
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HSR Review Summary Sheet ARC Use Only

Place in the following DSHR Member’s personnel health file

Name:

DSHR Number:

Date HSR Completed:

{Must be completed yearly}

Reviewed By:

Title:

Date Reviewed:

ARC Hardship Codes; Check all that apply:

None C7 Working Conditions

C1 Water Disruption C8 Limited Health Care

C2 Power Outage C9 Extreme Emotional Stress

C3 Limited Food Availability C10 Travel Conditions

C4 Extreme Heat and/or Humidity

Limitation

C11 Transportation

C5 Extreme Cold C12 Air Quality

C6 Housing Shortages C13 LiftingLimitation

Place the Hardship Code information in the DSHR System database under “Restriction Information”.

RH Restricted Hardship, note codes checked above

RM Restricted Medical

TI Temporarily Inactive

Comments:
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Pre-Assignment Health Questionnaire

This form is to be filled out by the person at the unit of affiliation that is responsible for DSHR 

deployment or their designee. If the unit should not have deployed the member based on their DSHR 

record, they may be charged for the member’s travel. 

Member Name DSHR# Requested for DR# 

1 Does the member have a current Health Status Record on file? Yes_ No If no, have 

member complete Health Status Record before continuing. 

2 Does the member have a medical restriction (RM) on their DSHR profile? Yes No If 

yes, do not recruit. The RM needs to be resolved first.

3 Verify any hardship codes associated with the relief operation. Does the member’s DSHR 

record include any of the hardship codes associated with this relief operation? Yes No If 

yes, do not recruit without clearance from the Chapter Health Reviewer. If the chapter 

does not have a Health Reviewer, the Division Health Consultant must be notified to

review the information prior to assignment and deployment.

Read the following statements to the member: “Do not give me any health information. Give 

me yes or no answers. If you fail to give accurate information and are not able to serve as 

recruited on the relief operation for health reasons, the Red Cross may request reimbursement 

for your travel.”

1 Are there any requirements for your group/activity/position on the Physical Capacity Grid that 

you cannot meet? (Chapter recruiters may need to read the requirements to the member). 

Yes No 

2 Do you currently have any stitches or areas of broken skin? Yes No 

3 Do you currently have a cast, brace or other device that restricts movement? Yes__ No 

4 Do you currently use a cane or other device to assist you? Yes No_ 

5 Have you been hospitalized or seen in the ER in the past six months? Yes No_ 

6 In the past three days, have you had any symptoms of illness such as fever >100 degrees, 

cough, sore throat, diarrhea, headache, flu –like symptoms etc.? Yes_ No 

7 Has anyone in your immediate family had the flu or flu like symptoms (fever >100 degrees, 

cough, sore throat, diarrhea, headache within the past 7 days? 

Yes No 

8 Have you been around anyone with the flu or flu like symptoms (fever >100 degrees, cough, 

sore throat, diarrhea, headache in the past 7 days?

Yes No 

9 Have you traveled outside of your normal commuting area in the past 10 days? Yes Where? 

 No 

10 Do you have any medical/laboratory tests scheduled within the next month? Yes_ No 

11 Have you started, changed or stopped any medications in the past 14 days? Yes No 

12 Will you need to refill any prescriptions during your assignment? Yes_ No 

If there are any “Yes” answers to these questions, the member must be approved by the Health

Reviewer before deployment.

Name of person obtaining information Date 

Name of Health Reviewer given the “yes” information above:

Retain this form in the member’s DSHR file in case it is requested by Staff Health at national 

headquarters, the Division Staff Health Consultant or Staff Health on the relief operation.

Rev 4/09 
21



Revised 7-10

Customer ServiceNetworkCommunicationCo

mputer Operations

Disaster Services Technology

TrainingStaff WellnessStaff RelationsStaff Planning and SupportLocal Community Volunteers

Staff Services

SupplyProcure

ment

Life, Safety and Asset ProtectionTransportationWarehousingIn-Kind DonationFacilitiesLogisticsFinanceFinancial & Statistical Info Manage

ment

Information Disse

mination

Disaster AssessmentInformation and PlanningFund RaisingPublic AffairsCommunity PartnersGovernment OperationsExternal RelationsSafe & Well LinkingBulk DistributionFeedingShelteringMass CareDisaster Mental HealthDisaster Health ServicesRecovery Planning & AssistanceClient CaseworkIndividual Client ServicesSite DiectorMulti-Site DiectorAssistant DirectorDirectorOperations Manage

ment

DSHR Group / Activity

RCS

RNT

RC

M

RCO

DST

TR

SW

SR

SPS

LCV

SS

SUP

PRO

LSAP

TRAWHS

IKD

FAC

LOG

FIN

FSI

ID

DA

IMS

FRPA

CPS

LGER

SWL

BD

FF

SH

MC

DMH

HS

RPA

CC

CLS

SD

MD

AD

Dir

OM



  



 



 



 



Lift / carry 20 lb Muliple 

times/shift

Physical 

Requirements



 



  



 

Lift / carry 50 lb Muliple 

times/shift



 



 



Stand for two-hour periods



Sit for 2 hours periods



 



  



Walk on uneven terrain



 



  



 Walk for two miles during 

a shift



 



 



 Bend or stoop multiple time 

a shift



 Crawl on the floor or ground



 



  



 



 



Work outdoors in inclement 

weather



  



 



 



 



Work in extreme heat and/or 

humidity



  



 



 



 



Work in extreme cold



  



 



 Able to step up/down

18 inches



 



 



  



Spend hours writing



Speak clearly on phone and 

in person

 



 



 



 



Read small print for 

extended periods



 



Work for long periods on 

computer



 



Climb two or more flights 

of stairs



 



Drive in day time and 

at night
22

OSHA Respirator Medical Evaluation Questionnaire

The following link is where one can find the OSHA Respirator Medical Evaluation Questionnaire, which is 

contained in Appendix C of OSHA standard 1910.134 Personal Protective Equipment. http://www.osha. 

gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9783