DOE G 440.1-4, Contractor Occupational Medical Program Guide for Use with DOE O 440.1

DOE G 440.1-4 06-26-97 CONTRACTOR OCCUPATIONAL MEDICAL PROGRAM GUIDE for use with DOE ORDER 440.1 OFFICE OF OCCUPATIONAL MEDICINE AND MEDICAL SURVEILLANCE DOE G 440.1-4 i 06-26-97 CONTENTS Page FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii I. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. APPLICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3. GENERAL INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4. GUIDELINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4.1 Implementation of an Onsite Occupational Medical Program . . . . . . . . . . . . . . . 7 4.2 Maintenance of a Healthful Work Environment . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4.3 Employee Health Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 4.3.1 Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 4.3.2 Health Evaluation Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4.3.3 Classes of Health Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4.3.3.1 Preplacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4.3.3.2 Medical Surveillance and Health Monitoring . . . . . . . . . . . . 11 4.3.3.3 Qualification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 4.3.3.4 Fitness for Duty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 4.3.3.5 Return to Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 4.3.3.6 Termination Health Evaluations . . . . . . . . . . . . . . . . . . . . . . 13 4.3.3.7 Voluntary Periodic Evaluations . . . . . . . . . . . . . . . . . . . . . . 14 4.3.3.8 Applicable Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4.4 Diagnosis and Treatment of Injury or Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4.4.1 Occupational Injury or Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4.4.2 Nonoccupational Injury and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4.4.3 Monitored Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4.5 Employee Counseling, Health Promotion, and Prevention . . . . . . . . . . . . . . 17 4.6 Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 4.6.1 Development and Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 4.6.2 Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 4.6.3 Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.6.4 Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.6.5 Work Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.6.6 Retention of Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4.6.7 Applicable Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

ii DOE G 440.1-4 06-26-97 CONTENTS (continued) 4.7. Emergency and Disaster Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4.7.1 Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4.7.2 Applicable Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 4.8 Organization and Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 4.8.1 Physician Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 4.8.2 Nurse and Other Occupational Health Personnel Staffing . . . . . . . . . . . 23 4.8.3 Professional Staffing Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 4.8.4 Clinical Psychologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 4.8.5 Counselors (i.e., Substance Abuse, Mental Health) . . . . . . . . . . . . . . . . 25 4.8.6 Psychological Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 4.8.7 Applicable Documents and Organizations . . . . . . . . . . . . . . . . . . . . . . . 26 4.9 Occupational Medical Facilities and Equipment . . . . . . . . . . . . . . . . . . . . . . . . 27 4.9.1 Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 4.9.2 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.9.3 Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.9.4 Applicable Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.10 Quality Assurance/Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 5. ADDITIONAL INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 DOE G 440.1-4 iii 06-26-97 FOREWORD This Department of Energy (DOE) Implementation Guide is approved for use by the Office of Environment, Safety, and Health, Office of Health Studies, Office of Occupational Medicine and Medical Surveillance, and is available to all DOE components and their contractors. Comments, recommendations, additions, deletions, and any pertinent data to improve this document should be sent to: George R. Gebus, M.D., M.P.H. Office of Occupational Medicine and Medical Surveillance EH-61/270 CC U.S. Department of Energy 19901 Germantown Road Germantown, MD 20874-1290 Phone: 301-903-7385 Fax: 301-903-5072 DOE Implementation Guides are a part of the DOE directives system and are issued to provide supplemental information regarding the Department's expectations for fulfilling its requirements (as contained in Rules, Orders, Notices, Manuals, Immediate Action Directives, and Regulatory Standards) or Policies. Implementation Guides identify acceptable methods for implementing these provisions; however, they do not establish requirements. In the interest of brevity and broadness of application, approaches and methods of implementation are normally discussed only in general terms in the Rules, Orders, Notices, Manuals, Immediate Action Directives, and Regulatory Standards. Implementation Guides provide more detailed iv DOE G 440.1-4 06-26-97 discussions of those approaches and methods, as well as other information useful in understanding

and implementing the requirements. They may also identify other acceptable principles and practices by referencing government or nongovernment standards. This Implementation Guide provides acceptable methods and approaches for implementing the requirements found in DOE O 440.1, WORKER PROTECTION MANAGEMENT FOR DOE FEDERAL AND CONTRACTOR EMPLOYEES. Applicable standards and procedures are included in a list following each section of this Guide. In addition, each section may include references which provide other sources of information. This Guide was prepared by the Office of Occupational Medicine and Medical Surveillance. DOE G 440.1-4 1 06-26-97 CONTRACTOR OCCUPATIONAL MEDICAL PROGRAM I. INTRODUCTION Protection of the safety and health of workers and the public and protection and restoration of the environment are fundamental responsibilities of the Department of Energy (DOE). A policy which promotes excellence in environmental, safety, and health activities is essential. To facilitate this policy, the Office of Environment, Safety and Health (EH) has been tasked with establishing a consistent and effective approach to resolve DOE-wide safety and health problems. Prompt recognition, diagnosis, and treatment of occupational injury or disease is paramount in managing and maintaining worker health. DOE Order (DOE O) 440.1, WORKER PROTECTION MANAGEMENT FOR DOE FEDERAL AND CONTRACTOR EMPLOYEES, Attachment 2 - Contractor Requirements Document (CRD), establishes the framework for an effective worker protection program that will reduce or eliminate accidental losses, injuries, and illnesses by providing workers with a safe and healthful workplace. The worker protection program integrates occupational safety, industrial hygiene, occupational medicine, construction safety, radiation protection, fire protection, firearms safety, explosives safety, motor vehicle safety, and other functions addressed in standards required by the Order. Section 18 of the CRD contains requirements for contractor occupational medical programs. The purpose of DOE O 440.1 is to establish a comprehensive worker protection program that ensures that DOE and its contractor employees are afforded a level of safety and health on the job that is at least equal to that provided to private-sector employees under the Occupational Safety and Health Act of 1970. The Order establishes a baseline program that can be used as the 2 DOE G 440.1-4 06-26-97 foundation for the type of proactive worker protection program that the best employers in private industry have established for their workplaces. This Guide will outline the methods and approaches which may be utilized to implement the contractor occupational medical program requirements of DOE O 440.1 and will provide assistance to contractors in meeting the following objectives: 1. Assist contractor management in protecting employees from health hazards in their work environments; 2. Assist contractor management in ensuring the placement of employees in work that can be performed in a reliable and safe manner consistent with the requirements of the Americans with Disabilities Act of 1990; 3. Provide support to contractor management in the medical, mental, and substance abuse aspects of personnel reliability and fitness for duty; 4. Promote the early detection, treatment, and rehabilitation of employees who are ill, injured, or otherwise impaired;

5. Apply preventive medical measures toward the maintenance of the optimal physical and mental health of employees through health promotion and education; 6. Provide professional guidance and consultation to contractor management on all health- related issues; 7. Provide employees, as appropriate, with professional medical evaluation, guidance, counseling, and referrals to specialists in support of optimal physical and mental health; DOE G 440.1-4 3 06-26-97 8. Protect the privacy of employees and the confidentiality of their medical records; and 9. Provide support to DOE and contractor management and to the Office of Health Studies/Office of Epidemiologic Studies by the collection and analysis, when requested, of employee health data for the purpose of early detection and prevention of occupational and nonoccupational illnesses and injuries, thereby reducing morbidity and mortality. 2. APPLICATION This Guide provides the approaches and methods that DOE finds acceptable to meet the requirements for a Contractor Occupational Medical Program, as defined in DOE O 440.1, and is applicable to all contractors awarded contracts and subcontracts for performing work for DOE on DOE-owned or -leased facilities. Activities conducted under the Naval Nuclear Propulsion Program or the Nuclear Weapons Safety Program relating to the prevention of accidental or unauthorized nuclear detonations are excluded from the application of DOE O 440.1. Adherence to this Guide will satisfy the requirements in DOE O 440.1. Specific requirements for the Federal Employee Occupational Safety and Health (FEOSH) Program are contained in 29 CFR 1960, Basic Program Elements for Federal Employee Occupational Safety and Health (FEOSH) Program and Related Matters, and DOE 3790.1B, Chapter VIII, and should be integrated with the overall Worker Protection Program that is provided for Federal employees. DOE elements and contractors are free to use the guidance provided in these nonmandatory documents or to develop their own unique methods, provided that these alternate methods afford workers a level of protection equal to or greater than that afforded by the nonmandatory Guides and Standards. 4 DOE G 440.1-4 06-26-97 3. GENERAL INFORMATION A contractor occupational medical program is established for the purpose of helping to provide for the safety and health of workers at DOE facilities through the provision of medical and other health-related services by qualified personnel who possess appropriate certification and training. The scope and nature of the medical services rendered are predicated, in part, on the analysis of existing or potential health hazards to which workers might be exposed, as well as specific job tasks. This can only be accomplished through close cooperation with professionals in industrial hygiene, health physics, safety, and management and through frequent worksite visits by medical staff. Employee fitness for duty is a foremost objective of contractor occupational medical programs, and the performance of health evaluations is essential to the process. High-priority evaluations include preplacement (health status and fitness for duty), medical surveillance (jobs involving specific physical, chemical, or biological hazards), qualification (job assignments with specific medical qualifications standards), return to work (ensure that the employee may return to work without undue health risk to self or others), job transfer (determine whether the employee's health

status and fitness for the newly assigned duties can be performed in a safe and reliable manner), and termination (health status review). Equally important is the creation, development, and maintenance of complete medical records for each employee in accordance with the provisions of the DOE Records Management Program. All components of an occupational medical program should be evaluated and prioritized with respect to their impact on worker health and safety at the site and their benefit/effectiveness in relation to cost in order to contain health care expenditures and to allocate funds in the most judicious manner. DOE G 440.1-4 5 06-26-97 The following definitions are useful for interpreting this Guide: 1. Contractor Medical Department. The occupational medical program or occupational medical department established by the contractor as required by the CRD. 2. Dedicated Medical Computer System. A computer system under the control of the occupational medical department designed to receive, collect, and store occupational medical information. 3. Employee Assistance Program (EAP). A program offering employees counseling, treatment, rehabilitation, and referral services for a wide range of medical, drug, alcohol, stress, and mental health problems, as well as for legal, financial, or job or career development problems. 4. Fitness for Duty. The determination that the physical and mental health of an individual is consistent with the performance of assigned duties in a safe and reliable manner. 5. Full-time Occupational Physician. A physician providing full-time occupational medical services. 6. Guidance. Information to assist in achieving the program policies and objectives. 7. Health and Safety Group. The contractor organizations which are concerned with health and safety programs. 8. Job Task Analysis. A statement outlining the physical and mental requirements and the potential exposures and hazards of a specific job. 6 DOE G 440.1-4 06-26-97 9. Monitored Care. The monitoring of the quality of medical care of employees who have extended absences from work due to illness or injury for the purpose of facilitating their rehabilitation, recovery, and early return to work. 10. Occupational Health Examiner (OHE). Physicians or nurse practitioners, physician assistants, or other appropriately licensed allied health professionals who provide health care under the direction of a licensed physician. 11. Occupational Health Nurse. A registered nurse providing occupational health nursing services under the direction of a licensed physician. 12. Occupational Medical Program. A program to assist in the maintenance and protection of optimal health through the skills of occupational medicine, psychology, and nursing; and to maintain a close interface with allied health disciplines, including industrial hygiene, health physics, and safety. 13. Occupational Medicine. Those specialty branches of the professions of medicine, nursing, and psychology which deal with the health protection and health maintenance of employees with special reference to job hazards, job stresses, and work environment hazards. 14. Part-time Occupational Physician. A physician providing occupational medical services on a less than full-time basis. 15. Site Occupational Medical Director. The physician responsible for the overall direction and operation of the site occupational medical program. DOE G 440.1-4 7 06-26-97

4. GUIDELINES DOE O 440.1 establishes the framework for an effective worker protection program that will reduce or prevent accidental losses, injuries and illnesses by providing DOE Federal and contractor workers with a safe and healthful workplace. The basic requirements for the establishment of a contractor occupational medical program are contained in the Contractor Requirements Document (Attachment 2). This Implementation Guide is intended to provide an acceptable approach for implementing the occupational medical requirements. For ease of reference, the subject headings found in this Guide parallel those in the Contractor Requirements Document. 4.1 Implementation of an Onsite Occupational Medical Program The establishment of an onsite occupational medical program should be the responsibility of the physician responsible for delivery of medical services. A formal written occupational medical plan detailing the methods and procedures used to meet the stated objectives should be established, maintained, reviewed, and updated as needed. Examples of medical program documents include mission statements, standing orders, policy and procedure documents, protocols, and memoranda of understanding. Occupational medical services may be provided by: 1. DOE contractor employees or 2. Private physicians or medical groups that are capable of fulfilling the requirements and intent of DOE O 440.1. 8 DOE G 440.1-4 06-26-97 4.2 Maintenance of a Healthful Work Environment Occupational medical physicians, nurses, and selected medical staff should maintain an ongoing familiarity and awareness of existing or potential work-related health hazards, employee job tasks, and worksite environments. Close cooperation and coordination with industrial hygiene, health physics, and safety professionals is suggested for the purpose of reviewing materials, processes, and procedures with an emphasis on physical, chemical, and biological hazards present in the worksite. Regular worksite visits should be conducted by physicians and selected medical staff and, when appropriate, coordinated with Industrial Hygiene, Safety, and Health Physics for the purpose of becoming knowledgeable and familiar with the work environment and potential hazards. Contractor management should routinely furnish the physician responsible for medical services with information on potential physical, chemical, and biological hazards at the worksite. This information is necessary to plan for worker protection programs, medical surveillance examinations, emergency planning, and staff training. Prior to the performance of a periodic health evaluation, contractor management should provide to the occupational health examiner (OHE) a summary of potential exposures to hazardous agents or tasks and all worksite exposures in excess of the Occupational Safety and Health Administration (OSHA)/DOE permissible exposure limits pertaining to the employee to be evaluated. DOE G 440.1-4 9 06-26-97 Job hazard and task analysis and exposure assessment are highly desirable tools for determining the need or rationale for medical monitoring. They should include personal monitoring results and systems that make exposure assessment data available. The occupational medical director or designee should have the opportunity to participate in new materials and process review committees, safety committees, and other health- related meetings to facilitate the exchange of information among worker protection team

members. 4.3 Employee Health Evaluations 4.3.1 Rationale Health evaluations should be conducted by an OHE under the direction of a licensed physician, using whatever ancillary assistance is needed in accordance with current, sound, and acceptable medical practices. Employee health evaluations should be used to provide initial and continuing assessment of the employee in order to: 1. Determine whether the employee's physical and mental health are compatible with the safe and reliable performance of assigned job tasks in accordance with the Americans with Disabilities Act of 1990; 2. Detect evidence of illness or injury and determine if there appears to be an occupational relationship; 3. Contribute to employee health maintenance by providing the opportunity for early detection, treatment, and prevention of disease or injury; 10 DOE G 440.1-4 06-26-97 4. Provide an opportunity for intervention by assessing risk factors which will cause premature morbidity or mortality (e.g., hypertension, smoking, elevated lipids); and 5. Maintain documented records of the physical and mental health experience of employees. 4.3.2 Health Evaluation Content The medical professional responsible for the occupational medical program should have responsibility for health evaluation content. Initial or baseline evaluations should be comprehensive, and follow-up evaluations should be additionally targeted as determined by employee exposure data, job task and hazard analysis information, or other occupationally related factors. Minimum elements of a comprehensive evaluation are: • medical/occupational history; • physical examination; • laboratory studies; and • review and evaluation of findings. The protocols for x-ray examinations should follow the recommendations and guidance contained in 43 FR 4377, dated 2-1-78. All radiographs should be interpreted by a qualified radiologist or as specified by OSHA/DOE. DOE G 440.1-4 11 06-26-97 4.3.3 Classes of Health Evaluations 4.3.3.1 Preplacement A medical evaluation of an individual should be conducted after the job offer, but prior to the performance of job duties, and in the case of current employees, prior to a job transfer. The health status and fitness for duty of the individual should be determined, thereby ensuring that assigned duties can be performed in a safe and reliable manner and consistent with the Americans with Disabilities Act of 1990. Contractor management should provide to the OHE a job task analysis pertaining to the applicant/employee to help assess any potential health risk. The initial preplacement evaluation should be a comprehensive evaluation as outlined in this Guide. The OHE should determine additional evaluation content, considering such factors as special physical or mental requirements of the job, potential hazardous exposures, or medical surveillance requirements mandated by the Occupational Safety and Health Act, 29 CFR 1910, or 29 CFR 1926. Those contractor operations requiring large numbers of preplacement evaluations may defer the comprehensive evaluation of individuals not assigned to hazardous work or potentially hazardous exposures after a review of the individual's medical history. The evaluations should be performed within 6 months of the hire date. The occupational medical professional performing employee health evaluations should be informed of all employee job transfers in order to determine whether a medical evaluation

will be necessary. 12 DOE G 440.1-4 06-26-97 4.3.3.2 Medical Surveillance and Health Monitoring Standards and requirements for special health evaluations and health monitoring of employees who work in jobs involving specific physical, chemical, or biological hazards should be in accordance with applicable OSHA/DOE standards. When employees are exposed to potential hazards not covered by regulations, appropriate special evaluations may be required as determined by the physician responsible for medical services and approved by the DOE Director, Office of Occupational Medicine and Medical Surveillance. 4.3.3.3 Qualification Evaluations should be conducted to qualify employees for specific job assignments for which specific medical qualification standards exist (e.g., drivers, pilots, protective force personnel, and respirator wearers). Special medical evaluations should be performed in response to contractor management's request to determine employee fitness for duty. 4.3.3.4 Fitness for Duty The OHE has the responsibility to make fitness-for-duty determinations. Employees should be evaluated for the presence of medical conditions that may reasonably impair their safe, reliable, and trustworthy performance of assigned tasks. DOE G 440.1-4 13 06-26-97 A substance abuse (drug and alcohol) identification and rehabilitation program is integral to a comprehensive fitness-for-duty program. Any testing provided should be in accordance with acceptable practices and applicable regulations. The goal is to promote a safe and healthy work environment and to rehabilitate employees involved with substance abuse. 4.3.3.5 Return to Work Occupational All employees with occupationally related injuries or illnesses should be evaluated before returning to work. The scope and content of this evaluation should be determined by the OHE, based upon the nature and extent of the injury or disease, and should be sufficient to ensure that the employee may return to work without undue health risk to self or others. The employee should obtain written clearance from the occupational medical department before returning to work. Nonoccupational Contractor management should ensure that employees will not be allowed to return to work until they receive a health evaluation and written clearance from the occupational medical department in the following situations: • illnesses or injuries causing absence from work for 5 consecutive workdays (or 40 hours) or more; • procedures or treatments that would negatively affect the employee's ability to perform in a safe and reliable manner; and • hospitalization. 14 DOE G 440.1-4 06-26-97 The employee should provide relevant medical information from their private physician to assist in this determination. The final decision for health-related work recommendations resides with the physician responsible for the medical program if a disagreement exists regarding return-to-work suitability. 4.3.3.6 Termination Health Evaluations A health status review should be made available for all terminating employees. This review should include the employee medical record and associated exposure information. A health evaluation (the content to be determined by the physician responsible for the medical portion of the occupational medical program) should be conducted on all employees with known occupational illnesses or injuries, employees with documented or

presumed exposures to hazardous substances as required by OSHA regulations, or when more than 1 year has elapsed since the last examination. All terminating employees should complete a signed response for the following questions: 1. Have you had any medical treatment or health changes since your last physical? 2. To your knowledge, have you had any significant chemical, radiation, or physical (such as heat or noise) exposures since your last physical? 3. Do you have any complaints or concerns related to prior illnesses, injuries, or exposures? 4. Do you have any current medical complaints? DOE G 440.1-4 15 06-26-97 4.3.3.7 Voluntary Periodic Evaluations Voluntary periodic evaluations may be offered. However, it should be recognized that specific work hazards or statutory requirements should take precedence over the voluntary program. A fundamental purpose of these evaluations is to provide employees with the periodic assessment of their health and serve as a basis for medical intervention. Accordingly, relevant components of the comprehensive evaluation may be included, as well as other preventive health measures such as health-risk appraisals or wellness counseling as authorized by the site medical director. 4.3.3.8 Applicable Documents 10 CFR 707, Workplace Substance Abuse Programs at DOE Sites 10 CFR 710, Criteria and Procedures for Determining Eligibility for Access to Classified Matter or Special Nuclear Material 42 CFR Chapter 1, Part II, Confidentiality of Alcohol and Drug Patient Records 49 CFR 40, Procedures for Transportation Workplace Drug Testing Programs DOE 5610.11, Nuclear Explosive Safety 10 CFR 1046.11, Medical and Physical Fitness Qualification Standards Public Law 102 484, Defense Authorization Act 29 CFR 1910.120, Hazardous Waste Operations and Emergency Response 16 DOE G 440.1-4 06-26-97 4.4 Diagnosis and Treatment of Injury or Disease 4.4.1 Occupational Injury or Disease The management of occupational injury or disease should be in accordance with the laws and regulations of the state in which the facility is located. Diagnosis and treatment of occupational injury or disease should be prompt, with emphasis placed on rehabilitation and return to work at the earliest time compatible with job safety and employee health. Contractor management has the responsibility to establish procedures to ensure that all employees with occupational injuries or illnesses receive medical clearance before returning to work. The responsible first-line management and health and safety groups (health physics, industrial hygiene, or safety) should be notified of unhealthy work situations detected by the occupational medical staff. 4.4.2 Nonoccupational Injury and Illness Employees should be encouraged to utilize the services of a private physician or medical facility, where these are available, for care of nonoccupational injuries or illnesses. However, the medical department should assist employees who become ill at work. Care should be available for what may be judged a short-term, self-limited condition. Such a policy will contribute to containment of medical costs and encourage an atmosphere of trust for employees. The objective is to return the worker to a state of health in the shortest possible time consistent with modern medical therapy. Long-term treatment of DOE G 440.1-4 17 06-26-97 nonoccupational injury and illness is not considered to be a routine responsibility of an

occupational medical program. NOTE: In emergencies, employees shall be given the necessary care required until referred to a private physician or facility. 4.4.3 Monitored Care Monitored care of ill or injured employees by occupational medical staff is highly desirable to maximize recovery and safe return to work and to minimize lost time and associated costs. Contractor management has the responsibility to advise and assist the occupational medical department when an employee has been absent because of an illness or injury for more than 5 consecutive workdays (or 40 hours), or has experienced excessive absenteeism. Worker's compensation cases should be monitored when appropriate through frequent return visits and physician-to-physician communication with private physicians where applicable. The goal is to assist the employees in their recovery and to facilitate their return to duty at the earliest practicable time, which may require reasonable accommodations consistent with the ADA of 1990. Coordination with managers, employee benefit programs, and human resource staff should be considered when developing a comprehensive monitored care program. 4.5 Employee Counseling, Health Promotion, and Prevention The physician responsible for the delivery of medical services should review and approve the medical aspects of an Employee Assistance Program (EAP), which should include physical and mental health, as well as alcohol and other substance abuse rehabilitation programs. 18 DOE G 440.1-4 06-26-97 Program evaluation should include treatment processes, records, referrals, treatment outcomes, follow-up (aftercare programs), and staffing. The physician responsible for the delivery of medical services should review and approve all contractor-sponsored or supported wellness programs as essential components of a preventive medicine program. Health counseling should be available to all employees. Program evaluation should address the training/education opportunities provided, lesson plans, class evaluation records, and referral counseling sessions. The responsible physician should ensure that training and immunization programs are available for workers potentially at risk of exposure to bloodborne pathogens and that the disposition of biohazardous waste conforms to OSHA regulations and Centers for Disease Control (CDC) guidelines. Applicable Documents 10 CFR 707, Workplace Substance Abuse Programs at DOE Sites 29 CFR 1910.1030, Bloodborne Pathogens 4.6 Medical Records 4.6.1 Development and Maintenance The occupational medical program should outline procedures for the creation and maintenance of a medical record for each employee for which medical services are provided. These records should be kept from the time of the first examination and should be accurate, current, and complete. DOE G 440.1-4 19 06-26-97 EAP records should be maintained separately by the EAP director to ensure confidentiality. 4.6.2 Confidentiality The confidentiality of all employee medical records, including written, microfilmed, or computerized records, should be observed by all persons having official access to them. Disclosure of information should be made only with the employee’s written consent, and access to employee medical records should only be granted as permitted by law or Federal regulation. Custody of the medical records should remain with the occupational medical department. 4.6.3 Access

Access to employee medical records should be in accordance with: 1. The Privacy Act, as codified in 10 CFR 1008.17(b)(1); 2. Access to Employee Exposure and Medical Records, as codified in 29 CFR 1910.20 (OSHA Standards); and 3. State laws and codes. 4.6.4 Identification Employee medical records should be properly identified and coded in a consistent manner to provide the medical staff with the following information: • current job title/work location, • job certifications or limitations, • allergies, and • medical surveillance/work hazards. 20 DOE G 440.1-4 06-26-97 This information is necessary to alert medical professionals to the identification of potential work-related conditions or fitness-for-duty considerations during examinations and treatments. Contractor management should assist the medical department in obtaining and updating this information. 4.6.5 Work Restrictions Appropriate work restrictions should be communicated to contractor management. Contractor management should maintain a work restriction registry, if appropriate. 4.6.6 Retention of Medical Records The medical records of contractor employees are considered valuable epidemiologic research records (along with other records such as exposure, work history, personnel, and litigation records) and should not be lost or destroyed. Inactive records may be retired to low-cost storage in an approved onsite records holding area or a Federal Records Center. They should be packed and sealed for storage so as to preserve confidentiality. If resources permit, the paper medical records may be stored on microfilm or any electronic media acceptable to DOE. 4.6.7 Applicable Documents DOE 200.1, INFORMATION MANAGEMENT PROGRAM, dated 9-30-96 10 CFR 1008, Records Maintained on Individuals (Privacy Act) 29 CFR 1910.20, Access to Employee Exposure and Medical Records DOE G 440.1-4 21 06-26-97 4.7. Emergency and Disaster Preparedness 4.7.1 Rationale The physician responsible for the occupational medical program should develop the medical portion of the site emergency and disaster plan. This input should be closely integrated with, and made a part of, the overall site emergency and disaster preparedness plan. It will require coordination and cooperation with management, emergency preparedness coordinators, safety, health physics, industrial hygiene, fire and rescue units, security organizations, and offsite medical facilities. The occupational medical portion of the site emergency and disaster plan should also be integrated with surrounding community emergency and disaster plans to the extent consistent with the development of a mutual aid and assistance capability. Preplanning and prearrangements are key factors vital to the effectiveness of the medical portion of the site emergency and disaster plan. The medical portion of the plan should be appropriate for the site. In formulating the plan, management should consider the type of plant operations, number of employees, emergency response capability, and the type and severity of accidents and trauma. Other considerations should include, where appropriate: 1. Capabilities for medical aid, triage, and personnel decontamination by trained, qualified medical staff members; 22 DOE G 440.1-4 06-26-97 2. Capabilities for cardiopulmonary resuscitation, cardiac defibrillation, and advanced cardiac life support; 3. Services of health physicists and industrial hygienists to evaluate any associated

radiological or chemical hazards affecting the casualties, the general public, or the environment, and to assist rescue and medical personnel; 4. Arrangements for adequate offsite treatment of injuries and illnesses resulting from exposure to radiation and/or toxic materials, including internal and external contamination; 5. Services of medical specialists and consultants; 6. Services of rescue squads, ambulances, and helicopters, as needed, with the capability of handling radioactively contaminated casualties as appropriate; 7. Medical aid coverage during evacuation operations from facilities and the site; and 8. Communication links between medical aid and triage teams, fire and rescue units, hospitals and hospital teams, local and State police, and the DOE Emergency Operating Center. 4.7.2 Applicable Documents DOE 151.1, COMPREHENSIVE EMERGENCY MANAGEMENT SYSTEM, dated 9-25-95 DOE G 440.1-4 23 06-26-97 U.S. Department of Transportation guides and appropriate State requirements for ambulance personnel The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) and the Superfund Amendments and Reauthorization Act of 1986 (SARA) The Resource Conservation and Recovery Act (RCRA) The Emergency Planning and Community Right-to-Know Act (EPCRA) Executive Orders 12580 and 12656 Title 40 CFR 300, National Oil and Hazardous Substances Contingency Plan Title 40 CFR 302, Designation, Reportable Quantities, and Notification Various Federal Plans for responses to manmade and natural disasters (e.g., the Federal Radiological Emergency Response Plan, the Federal Radiological Monitoring and Assessment Plan, and the Federal Response Plan) 4.8 Organization and Staffing 4.8.1 Physician Staffing Physicians who are providing occupational medical services to contractor employees need to have a degree from an accredited school of medicine or osteopathy and meet the licensing requirements applicable to the locations in which they work. Board certification in occupational medicine is preferred. It is desirable that the responsible physician report 24 DOE G 440.1-4 06-26-97 to the contractor site manager, appropriate laboratory director, or another management level with sufficient authority to participate in health and environmental issues at policy- making levels to ensure program effectiveness. They should be afforded opportunities for continuing education, including attendance at professional meetings. 4.8.2 Nurse and Other Occupational Health Personnel Staffing It is recommended that occupational health nurses, physician’s assistants, nurse practitioners, and other occupational health personnel be graduates of accredited schools, licensed, registered, or certified, and legally qualified to practice by Federal or State law where employed. They should be afforded opportunities for continuing education, including attendance at professional meetings. 4.8.3 Professional Staffing Ratio The proper professional staffing ratio of physicians and nurses to the employee population is related to many factors that may include the following: • size of population to be served; • geographic distribution and location of employees; • shifts worked; • rate of employee turnover; • age and distribution of the employee population; • extent of occupational hazards and associated medical surveillance requirements; • types and complexities of job tasks and operations performed;

• total number of all health examinations required; • degree of isolation of worksites from the community and its medical services; and • degree of employee utilization of occupational health services. DOE G 440.1-4 25 06-26-97 At sites where a full-time nurse or physician would not be cost effective (e.g., sites with less than 300 employees), management should provide at least one employee on duty that is trained and currently qualified in first aid and cardiopulmonary resuscitation. 4.8.4 Clinical Psychologists 1. Should be graduates of accredited schools of clinical psychology and hold a valid license as required in the state where they work. A Doctor of Philosophy (Ph.D.) or a Doctor of Psychology (Psy.D.) degree with training and experience in clinical occupational assessment and treatment is highly desirable. 2. Should report directly to the site occupational medical director or designee. 3. Should be afforded opportunities, as determined by the site occupational medical director, for continuing psychological education related to services provided on the site, including psychological evaluation. Psychologists employed full-time should be afforded opportunities for membership and participation in professional associations. 4.8.5 Counselors (i.e., Substance Abuse, Mental Health) 1. Should have the education and training appropriate to their specialty and be certified or licensed as required by the state in which the facility operates. 2. Should be responsible to the site occupational medical director or designee. 3. Counselors employed full-time should be afforded opportunities for continuing education and membership and participation in professional associations as approved by the site occupational medical director. 26 DOE G 440.1-4 06-26-97 4.8.6 Psychological Staffing The site occupational medical director should establish consulting relationships with psychiatrists or psychologists as required by the demands of the program. At sites with 2,000 or more employees, one full-time equivalent clinical psychologist is desirable. The option of contracting for the services of a part-time clinical psychologist or psychiatrist for facilities with fewer than 2,000 employees or to supplement existing services is acceptable. 4.8.7 Applicable Documents and Organizations State Practice Acts American Association of Occupational Health Nurses, 1994 Standards of Occupational Health Nursing Practice The American Association of Occupational Health Nurses, 50 Lenox Pointe, Atlanta, GA 30324-3176 American Board for Occupational Health Nurses, Inc., 10503 N. Cedarburg Road, Mequon, WI 53092-4403 American Academy of Nurse Practitioners, Capitol Station, LBJ Building, P.O. Box 12846, Austin, TX 78711 DOE G 440.1-4 27 06-26-97 American Academy of Physician Assistants, 950 N. Washington Street, Alexandria, VA 22314; contact Ellen Rathfon at 703-836-2272 for information about Scope of Practice American College of Occupational and Environmental Medicine U.S. Department of Health and Human Services, Public Health Service, Division of Occupational Medicine 29 CFR 1910.151, Medical Services and First Aid American Psychological Association, Standards and Guidelines for Professional Psychological Practice American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders DSM-IV Employee Assistance Professionals Association (EAPA), Standards and Guidelines State Licensing Boards for the Practice of Psychology

National Professional Counselors Association Alcohol and Substance Abuse Counselor Association Mental Health Counselors Association State Counselor Licensing Departments 28 DOE G 440.1-4 06-26-97 4.9 Occupational Medical Facilities and Equipment 4.9.1 Facilities Occupational medical program facilities should have sufficient space, lighting, and climate control and should be adequate for the privacy and comfort of employees for waiting, consultation, examination, and emergency treatment. Occupational medical facilities should be located in areas readily accessible to employees and transportation. Adequate decontamination facilities for chemical and radiological purposes should be readily available when the potential for those hazards exists. 4.9.2 Equipment Selection, supply, and use of medical equipment should be adequate in terms of present- day accepted standards of medical practice, should meet OSHA standards, and should be properly maintained and calibrated. 4.9.3 Pharmaceuticals Dispensing, storing, and disposing of pharmaceuticals should be in accordance with appropriate Federal, State, and local law. 4.9.4 Applicable Document State Pharmacy Act DOE G 440.1-4 29 06-26-97 4.10 Quality Assurance/Quality Improvement Each contractor occupational medical department should strive to develop, maintain, update, and continuously improve a quality plan that exemplifies the organization's mission and vision, quality values, and customer focus orientation. The quality plan should contain provisions that address customer service strategies, that analyze service delivery systems, and that develop customer service standards, with the goal of empowering employees and reinforcing and rewarding excellence. Applicable standards regarding equipment, procedures, and documentation may also be used. Applicable Document 10 CFR 830.120, Quality Assurance 5. ADDITIONAL INFORMATION For site-specific questions concerning the implementation of DOE O 440.1, contact your DOE Operations Office's or DOE contractor organization’s Worker Protection Manager. EH-51 also develops and disseminates interpretations of DOE worker protection standards. A toll-free response line has been established to address requests for interpretations. Precedented requests for interpretations are maintained in a database and usually can be addressed within a few minutes. Unprecedented requests are addressed with a written response, usually within 20 working days. The Standards Interpretations Response Line telephone number is 1-800-292- 8061. Hours of operation are 8 a.m. to 4 p.m. (Eastern time), Monday through Friday. For additional information about the DOE Contractor Occupational Medical Program or concerning implementation of the occupational medical requirements of DOE O 440.1, contact Cherry Keller in the Office of Occupational Medicine and Medical Surveillance (EH-61) at 301-903-9846.