Manual for The Medical and Physical Examination Program

State of Georgia

Manual for

The Medical and Physical

Examination Program

Department of Administrative Services

July 1, 1961

Revised July 1, 1964

Revised April 1, 1969

Revised July 1, 1975

Revised January 26, 1977

Adopted August 17, 1977

Revised February 17, 1982

Revised June 30, 1997

Revised January 1, 1998

Revised June 30, 1999

Revised October 15, 2004

Revised February 15, 2005

Revised July 1, 2006

Revised July 23, 2008

Revised February 1, 2011

Revised July 1, 2012

Revised May 1, 2017

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

Summary of Change

Medical and Physical Evaluation Program (MAPEP)

This revision —

 Removed MAPEP Form 10-500, Health Informatio

n Checklist.

 Inserted the

current version of the General Information form (MAPEP 10

-51-03) that

replaced form MAPEP 10-51-03.

 Updated job titles and references.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

Proponent Authority

Medical and Physical Examination Program

Standards of Pre-employment Medical and Physical Fitness

History: This publication is a revision of the MAPEP Guidelines. The portions affected by this

revision are listed in the Summary of Change.

Summary: This publication provides information, policies and procedures for pre-employment

standards of medical and physical fitness. It implements SPB Rule 478-4-.03 (2) (b), which is

authorized by O.C.G.A. 45-2-40 et.seq.

Applicability: This publication applies to candidates for employment with the State of Georgia,

including state agencies, authorities, colleges and universities, community service boards and other

state government entities.

Authority: The proponent of these guidelines is the Department of Administrative Services. The

proponent has the authority to make revisions and clarifications to these guidelines that are consistent

with controlling law and regulation.

Suggested improvements: Users are invited to send comments and suggested improvements to the

DOAS Human Resources Administration, MAPEP Coordinator, at 200 Piedmont Avenue, West

Tower, Atlanta, GA 30334.

Distribution: This publication is available online and is intended for the use of individuals with

MAPEP related responsibilities.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

TABLE OF CONTENTS

I. PROGRAM OBJECT

IVES ........................................................................................................ 5

II. JOB CATEGORIES .................................................................................................................... 6

A. GENERAL .......................................................................................................................... 6

B. OVERVIEW ...................................................................................................................... 7

III. MAPEP PROCEDURES ............................................................................................................. 9

A. OVERVIEW ………………………………… ………………. ......................................... 9

B. PHYSICAL EXAM NOT REQUIRED (Typically jobs in categories 1 – 4) ................... 10

C. PHYSICAL EXAM REQUIRED ..................................................................................... 11

D. JOB DATA ........................................................................................................................ 12

E. JOB CATEGORY DESIGNATION ................................................................................. 13

F. ADDITIONAL TESTS REQUESTED/PHYSICAL EXAM REQUIREMENT .............. 13

G. APPEALS/ACCOMMODATIONS .................................................................................. 14

IV. GENERAL MEDICAL GUIDELINES ................................................................................... 15

V. SPECIALIZED MEDICAL GUIDELINES ............................................................................ 16

VI. FORMS ....................................................................................................................................... 19

VII. APPENDICES ........................................................................................................................... 33

A. APPENDIX A – O.C.G.A. 45-2-40 .................................................................................. 34

B. APPENDIX B – SPB 478-4 .............................................................................................. 38

C. APPENDIX C – FUNCTIONAL REQUIREMENTS WORKSHEET ............................ 45

D. APPENDIX D – O.C.G.A. 34-9-368 ................................................................................ 50

E. APPENDIX E – GLOSSARY .......................................................................................... 52

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

MEDICAL AND PHYSICAL

EXAMINATION PROGRAM (MAPEP)

I. PROGRAM OBJECTIVES

As defined by 1981 Opinion of the Attorney General Number 81-23, the legislative intent of

O.C.G.A. 45-2-40 is:

 To insure the prospective employee will be physically capable of carry

ing out the duties

of his or he

r appointme

 To protect the prospecti

ve employee from possible harmful effects associated with hi

ployment, which may arise by virtue of a particular preexisting physical ma

lady

 To protect the state from

potential liability under workers' com

pensation laws for

conditions arising after em

ployment, but caused in whole or part by preexisting phys

ical

conditions

Additionally

, the MAPEP is designed:

 To provide a consistent, job-related process for determining and applying the me

dical and

phy

ical standards

 To provide for administrative procedures that are straightforward, clear, and minimal

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

II. JOB CATEGORIES

Category 1:

Primarily sedentary, light physical work with limited to no unusual working

conditions (e.g. Administrative Assistant; Business Operations Manager; Human

Resources Specialist).

Category 2:

Moderate to heavy physical activity and/or moderate to high interface with working

conditions of potential concern for certain health conditions (e.g.,

Supply/Warehouse Clerk; Housekeeper; Mechanic).

Category 3:

Positions involving food preparation or the handling of raw consumable animal

products (e.g., Food Service Worker; Plant Operator; Agriculture Inspector).

Category 4:

Health-related positions involving direct contact with or exposure to airborne or

blood-borne pathogens (e.g., Nurse Manager; Health Aide; Radiologist; Dental

Hygienist).

Category

5 (Law Enforcement) positions involve the highest level of physical activity. Most of

these positions would be involved in violator apprehension and other enforcement duties involving

extreme or potentially life-threatening working conditions and requiring high levels of physical

capability. As a general rule, POST-certified positions would be in this category.

Because of the

potential recurring exposure to human body fluids and close public contact, the medical reviews

include health screens consistent with Category 4 positions in addition to the more in-depth

examination for the assessment of overall physical condition.

Exception: Certain POST-certified positions, such as Probation Officers, may not involve consistent levels of

strenuous physical activity sufficient to warrant completion of the physical examination requirement. Agency

policies covering exemptions should include justification and documentation on a case-by-case position-specific

basis.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

MAPEP review for Category 5 positions involves:

Examples of typical Category 5 titles include: Trooper, Special Agent, Compliance Investigator,

Facilities Police Corporal, Correctional Officer, Public Safety Cadet, Criminal Investigator,

Prevention Specialist, and Conservation Ranger.

III. MAPEP Procedures

A. OVERVIEW

1. The MAPEP paperwork and review pro

cess must be completed after an offer of employment

but before disbursement of salary. (NOTE: Any required physical examination must be

completed prior to the date of appointment, and the reporting of results shall be completed

within 40 calendar days of appointment. (See Appendix B.)

2. If no physical examination is indicated, typically jobs in Categories 1 - 4, the "General

Information" form (MAPEP 10-51-03) will be completed. (See B. below.)

3. For jobs in Category 5, or other position for which a physical examination is indicated, the

"General Information" form (MAPEP 10-51-03) and appropriate Medical History forms will

be completed and a physical examination arranged. (See C. below.)

4. All medical history forms used for Categories 2-5, if indicated, and physical examination

results (typically Category 5), will be reviewed by a licensed physician in the employ of or

under contract with the state or respective employing agency for determination of the medical

and physical fitness of the prospective employee. The results of this determination should be

reported to the employing agency on the “Medical Examination Report to Employing

Agency” form (MS 10-57).

5. The physical demands of the position and the working conditions under which work is

performed will be compared with the health status of the prospective employee. Also, any

standards and/or guidelines approved by the State Personnel Board (See Sections IV and V)

will be considered in the review.

Exception: Certain POST-certified positions, such as Probation Officer, may not involve consistent levels of

strenuous physical activitysufficient to warrant completion of the physical examnation requirement. Agency policies

covering exemptions should include justification and documentation on a case-by-case position-specific basis.

 a "General Information" form (MAPEP 10-51-03)

AND

 a medical/physical examination by a licensed physician, covering all major body

systems and functions and emotional/mental functioning (MS 10-56)

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

6. A report based on the results of this review will be sent to the employing agency as follows:

a) Physically capable to meet demands of position with:

(1) No limitations

(2) Moderate limitations (not to be transferred to another position without review of

medical records)

b) Recommend further examination(s)

c) Does not meet the physical standards of the position

d) Incomplete or inadequate information

7. Upon completion of the MAPEP process, all forms and materials will be kept by the

employing agency. The agency should keep copies of all MAPEP forms. All MAPEP forms

and medical or health-related materials must be filed separately from the employee's

personnel records.

NOTE: All medical data must be treated as confidential by the examining physician, and

the employing agency.

B. PHYSICAL EXAMINATION NOT REQUIRED

(Typ

ically jobs in Categories 1 - 4.) If the position does not require a physical examination:

1. The employing agency and prospective employee will complete the "General Information"

form (MAPEP 10-51-03).

2. The completed MAPEP form and any job information attachments (see D. below) will be

retained by the employing agency.

3. For Category 1 through 4 positions, if the employing agency finds upon review of the

MAPEP materials that the prospective employee appears capable of performing the duties of

the position, no further assessment is needed. If, upon review of the MAPEP materials, the

employing agency finds information that it feels needs review by a medical practitioner, the

forms should be referred to a physician in the employ of or under contract with the state or

agency, for further review. If the employing agency finds that a physical examination is

necessary, the employing agency will designate "Additional Test(s) Requested" on the

Medical Findings Form (MS 10-56) and refer the prospective employee to a physician in the

employ of or under contract with the state or department, or a licensed medical practitioner of

the prospective employee's choice.

NOTE: The licensed medical practitioner will assume that there are no atypical or special job

duty demands or other factors affecting job performance unless such information is provided by

the employing agency (see D. below).

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

C. PHYSICAL EXAMINATION REQUIRED

If a physical examination is required:

1. For job po

sitions, typically Category 5 jobs, for which an examination is initially required

a) The em

ploying agency will complete appropriate sections of the MAPEP "G

eneral

Information" form (MAPEP 10-51-03). The employing agency will also complete the

"Additional Tests Requested" (page 1, top left) if any; and the "Employer Name and

Address" (page 3, bottom right) portions of the "Medical Findings" physical examination

form (MS 10-56). The employing agency

will provide copies of the "General Medical

Guidelines"

(Section IV) and the "Specialized Medical Guidelines" (Section V) as

attachments to the memorandum to the Examining Physician" (MS 10-55). The

ploying agency will also indicate which other completed form

s (ex. MS 10-52) are

being provid

ed with these "Guidelines" as part of the medical package by

checking the

appropriate b

oxes on the cover memorandum to the Examining Physician (MS 10-55).

b) The prospective employee will complete appropriate sections of the "General

Inform

ation" form (MAPEP 10-51-0

3).

c) The agency will retain a copy of the "G

eneral Inform

ation" form

(MAPEP 10-51-03).

The prospective e

mployee will be referred with the MAPEP medical

package --

completed forms (a copy of MAPEP 10-51-03), the job information attachments (see D.

below), the "Medical Findings" form (MS 10-56), and the physician cover memorandu

(MS 10

-55) with general and specialized standards attached -- for physical examination

to one of the

following:

(1) A licensed physician in the em

ploy of or under contract with the state or respective

employing department.

(2) A licensed m

edical practitioner of the applicant/prospective employee's choice and

at the applicant/prospective employee's expense

NOTE: Age

ncies may provide for physician services at agency expense and may stipulate

that prospective employees be examined by the designated provider. For such prior

arranged examinations, the job information attachment and the physician cover

memorandum (MS 10-55) may be omitted as long as a process is in place to assure

thorough job knowledge by examining physicians. (See D. 5-7 below.)

d) The licensed medical practitioner will send the completed medical package to the

designated representative of the employing/referring agency.

e) The employ

ing/referring agency will retain all MAPEP forms and medical or health-

related materials in separate files from the employee's personnel records.

2. For job positions for which a physical examination has been indicated after initial review

of appropriate MAPEP materials by the me

dical reviewer:

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

a) The employing agency will notify the prospective employee and will complete the

"Additional Tests Requested" and the "Employer Name and Address" po

rtions of the

"Medical Findings" ph

ysical examination form (MS 10-56). Also, the employing agenc

will identify

the general and specialized standards and the medical history form

s (ex. MS

10-52) inclu

ded in the medical package by checki

ng the appropriate boxes on the cover

memorandum to the Examining Physician (MS 10-55).

b) The entire medical package -- i.e., the "General Information" form (MAPEP

10-51-03),

any

attached job information, the job-category-designated medical history forms (MS 10-

52), the "Medical Findings" form (MS 10-56) and the physician cover memorandum

(MS

10-55) – will be provided to the prospective employee. The prospective employee will

be referred

to a physician for physical examination as in 1.c), above. (Agency retains a

copy of the "General Information" form MAPEP 1

0-51-03.)

c) Processin

g then duplicates 1.d) and 1.e) above.

D. JOB

DATA

1. Prior to filling each vacancy, job requirements and job information documentation should be

reviewed an

d updated as

needed.

2. Essential fun

ctions should be determined and documented.

3. Detailed job information should be provided to all considered candidates.

4. Reasonable a

ccommodation of candidates with disabilities should be consider

ed, as required.

NOTE:

A useful worksheet (MS 10-59) for determining and documenting position functi

onal

requirements and environmental factors is provided in Appendix C.

5. The ty

pe of job data provided to the medical reviewer and/or examining physician sho

uld be

identified in Section B of

the MAPEP "General Information" form (MAPEP 10-51-03).

6. It is recommended that, at a minimum, the provided job data attached to the "General

Information" form (MAPEP 10-51-03) be an updated description of key re

sponsibilities that

includes an indication of essential functions. It is recomm

ended that, over time, more

thorough

inform

ation, such as functional requirements and environmental factors, be developed and

provided, as well. (See Appendix C).

7. For sedentary, office positions (Category 1) it is not necessary to attach job information to

MAPEP 10-51-03. (Be sure to document any notable or unusual job requireme

nts or working

conditions in Section B of MAPE

P 10-51-03.) For other positions (Categories 2-5) it is

recommended that job information accompany MAPEP 10-51-03 to ensure that lic

ensed

medical practitioners have a detailed description of the job duties to be performed by the

prospective em

ployee. If other methods are in place to assure thorough understanding of job

requirements and standards, (e.g., exclusive use of facility or contract physician to whom

detailed data have been supplied up front), this step may not be necessary.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

8. REMINDER:

a) Be sure to document any notable or unusual physical/functional requirements

environm

ental factors/working conditions in Section B of MAPEP 10-51-03.

b) Be sure to describe any needed reasonable accommodations in Section B of MAPEP

10-51-03.

E. JOB CATEGORY DESIGNATION

1. As stated above, each agency decides the category designation of each position. This

designation may be done as vacancies occur or it may be done agency wide by occupational

category, with exceptions handled as vacancies occur. Each agency should develop a

policy to describe how this process is to be ha ndled. General guidance and discussion of

designation considerations may be obtained by contacting the Department of Administrative

Services.

2. The main issue in the job category designation is the nature of the work of each position. A

certain degree of consistency and similarity is expected across same-titled positions.

Significant dissimilarities may indicate that closer analysis is warranted to assess potential

issues involving the job classification of the position. However, the main goal should be an

identification of the category that most closely links the prescribed medical assessment with

the physical requirements and the working conditions of the position.

3. Documentation that discusses the job-relevance of typical categorizations should be

developed and retained in agency files.

F. "ADDITIONAL TESTS REQUESTED"/PHYSICAL EXAM REQUIREMENT

1. For certain positio

ns, regardless of job category designation, agencies may stipulate an

agency-paid physical and/or psychological examination a

s long as such examinations can

be justified by job duty requirements. Care should be taken to assure focus on job duties

and on linking the requirements consistently to the position.

2. Also for certain positions, there are job-related reasons for certain laboratory tests or physical

examinations beyond

those considered in a routine physical examination. Where

supportable, req

uests for these tests may be made by an agency in the "Additional Tests

Requested" section of the "Medical Findings" (MS 10-56) physical examination form.

3. Specific guidelines approved by the State Personnel Board (See Section V) discuss

considerations for laboratory tests and other medical analyses beyond the general physical

examination. In most cases, such further analyses are triggered either by information

cumented on the “General Information” form (MAPEP 10-51-03) or by results of the

eneral physical examination. Such findings become part of the employing department's

medical file to be evaluated by the licensed medical practitioner.

4. For any positions, regardless of job category designation, the employing department or

medical reviewer may request further medical information and/or may request further

physical examination(s) or test(s). Such requests may be made in cases where medical

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

information provided indicates a potential job-related problem and/or where insufficient

information is available for appropriate determinations to be made.

G. APPEALS/ACCOMMODATIONS

1. Medical and physical guidelines/standards have been established with deliberation and

consolidation of com

plex information on medical conditions and physi

cal/functional job

requirem

ents. In the majority of cases, the soundness of the established standards would be

expected to be reaffirmed.

2. However, it is understood that special, individual circumstances may arise that might justify

a modification or waiver of a specific guideline/standard. In such cases, a review of the facts

and circumstances can be obtained by following procedures discussed in Appendix B.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

IV. GENERAL MEDICAL GUIDELINES

[Approved February 24, 1994; Revised December 17, 1997]

Medical History: Free from any medical or physical condition that would interfere with

performance

of job duties and responsibilities.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

V. SPECIALIZED MEDICAL GUIDELINES

[Approved February 24, 1994; Revised May 22, 1997; Revised December 17, 1997; Revised October 15, 2004, February 15, 2005]

MEDICAL AND PHYSICAL EXAMINATION PROGRAM (MAPEP)

Candidates for "Category 5" positions must meet the requirements set forth in the General Medical

Guidelines plus the following specific physical standards.

A. General:

Height and weight should not be such as to interfere with specific job activities.

B. Vision: 1) Distant vision -- minimum vision of 20/40 in each eye, corrected (with glasses or

contact lenses) and at least 20/100 in each eye uncorrected (without glasses or contacts). 2) Near

vision -- minimum of 20/40, corrected or uncorrected in each eye. 3) Adequate depth perception

and the ability to distinguish colors. 4) Peripheral vision -- at least 70 degrees in each eye.

All Category 5 positions are subject to the guidelines above for 2) Near Vision, 3) Depth

perception and the ability to distinguish colors, and 4) Peripheral Vision. The following are

position specific exceptions to the 1) Distant Vision guidelines only.

• For GBI: Special Investigation Agent series only: 1) Distant vision -- minimum vision of

20/20 in one eye and 20/40 in the other eye, corrected (with glasses or contact lenses), and

minimum of 20/200 in each eye, uncorrected (without glasses or contacts).

• For Trooper/ GSP series only: 1) Distant vision -- minimum vision of 20/40 in each eye,

corrected (with glasses or contact lenses), and minimum of 20/60 in each eye, uncorrected

(without glasses or contacts).

• For Correctional Officer series, Firefighting & Fire Prevention Specialist series,

Probation Officer series, and Parole Officer series: 1) Distant vision -- minimum vision

of 20/40 in each eye, corrected or uncorrected (with or without glasses or contact lenses).

C. Hearing: Hearing loss no greater than 24dB (decibels) for the average of frequencies 500Hz,

1000Hz, 2000Hz, and 3000Hz in the better ear, unaided (without a hearing aid) or aided (with a

hearing aid).

“Normal hearing” is a hearing loss no greater than 24 dB at 250Hz, 500Hz, 1000Hz, 2000Hz,

3000Hz, 4000Hz, 6000Hz, 8000Hz in both the right and left ears, unaided.

• An Otoscopic examination is required prior to the air conduction audiogram.

• A complete pure tone or warble tone air conduction audiogram is required and results

recorded for all candidates. The audiogram must be completed at all frequencies listed on

Form MS 10-56 on both the right and left ears. The pure tone air conduction audiogram is

to be used as the baseline audiogram.

o If the testing indicates air conduction thresholds to be within the stated hearing

guidelines for employment, no further hearing testing is necessary. However, if any

single air conduction threshold is obtained outside the normal, 0-24dB range; i.e., if

hearing is not within “normal limits”, the results of the test are explained to the

candidate and the recommendation is made to obtain a complete audiological evaluation

at the individual’s expense for his/her own hearing healthcare benefit.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

o If the testing indicates air conduction thresholds to be outside the stated hearing

guidelines for employment, the results of the test are explained to the candidate and a

complete audiological evaluation is recommended, at the individual’s expense for

his/her own hearing healthcare benefit.

o In addition to the pure tone air conduction testing, warble sound field testing is required

and results must be recorded for all candidates who wear a hearing aid and do not meet

the guidelines on the air conduction test, to verify if an individual meets the guideline

for employment with the use of a hearing aid. If the site does not have the personnel or

equipment to satisfy this requirement, then a referral is indicated.

• A qualified individual

should administer the audiometric testing and perform the otoscopic

examination. Qualified individuals include licensed audiologists, otolaryngologists,

physicians trained in hearing conservation, technicians who are certified by the Council for

Accreditation of Occupational Hearing Conservation, or technicians trained by such a

physician. A technician who performs audiometric tests must be responsible to an

audiologist, otolaryngologist, or physician.

• All tests should be performed in an acoustic environment to meet the current ANSI standards.

• All audiometric equipment should be calibrated annually to meet current ANSI standards.

D. ENT: There should b

e adequately free nasal breathing. The mouth should be free from

deformities or conditions that interfere significantly with distinct speech.

E. Cardiovascular: Rheumatic and congenital heart disease should be thoroughly evaluated by

the examining physician and commented on in the examination report.

Atherosclerotic (arteriosclerotic) heart disease, myocardial infarction, coronary insufficiency,

angina pectoris, and hypertension above 140/90 must be evaluated on an individual basis and

must not

be of sufficient severity to interfere with the performance of all duties.

F. Respiratory: Free of infectious diseases or other pulmo

nary processes that would interfere with

the physical demands of the position.

G. Gastrointestinal: Must be free of any major pathological conditions that will interfere with the

performance of physical requirements of the position.

H. Rectum a

nd Anus: Major hemorrhoidal conditions and symptomatic pilonidal cysts must not be

of sufficient severity to interfere with the job.

I. Hernia: Hernia (E) which might interfere with the performance of duty would require

surgical repair with clearance from

operating surgeon, prior to employment.

J. Genital/Urinary: Large varicocele or hydrocele, which might interfere with the performance

of duties, should be repaired with clearance from operating surgeon prior to employment.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

K. Back and Neck: History of significant injury, deformity, surgical procedure, or other spinal

pathology should be thoroughly evaluated by the examining physician and commented on the

examination report.

L. Extremities: *If a prosthesis or orthosis is used, such prosthesis or orthosis must not

interfere with the performance of duty. 1) Upper Extremities -- both hands must have at least

the index, middle, and one other finger and must not interfere with the performance of duty; both

thumbs must be functional; or see (*) above. 2) Lower Extremities -- both lower extremities must

be free from limitation of any joint motion which would interfere with the performance of duties;

both great toes must be functionally normal; or see (*) above.

M. Nervous System: Central and peripheral nervous system disorders must be evaluated by the

medical examiner. Applicants with seizures must be thoroughly evaluated by the examining

physician and all findings included in the examination report. Special attention must be given to

any history of seizure activity.

N. Emotional Stability: Any history of significant emotional instability or mental illness should be

thoroughly evaluated by the examining physician and commented on in the examination report.

O. Laboratory Analysis: Items 1 through 4 are not required unless medical history or physical

examination results indicate that such tests are needed to adequately assess the applicant's

physical status. Item 5 is required for Correctional Officers (including Juvenile Correctional

Officers) only.

1. Urinalysis (Multi-Test Stick): Abnormalities in the sugar and albumin tests must be evaluated

further. If Glycosuria is significant, must have Glucose Tolerance Test and if albuminuria,

must have the cause identified.

2. Hemoglobin or Hematocrit.

3. Chest x-ray.

4. Resting Electrocardiogram.

5. Tuberculin Skin Test. (For Correctional Officer Series Only) If there is a positive reaction

of 10mm or greater, a chest x-ray is required to document the absence of tuberculosis.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017

VI. FORMS

 MAPEP 10-51-03 .. General Information

 MS 10-52

............... Medical History Report (Optional)

 MS 10-55 ............... Memorandum to Examining Physician

 MS 10-55A ............. Memorandum to Reviewing Physician

 MS 10-56 .............. Medical Findings

 MS 10-57 .............. Report to Employing Agency

MAPEP 10-51-03 (2006) Page 1

GENERAL INFORMATION

MEDICAL AND PHYSICAL EXAMINATION PROGRAM

(MAPEP)

Inquiry Authority/Use Statement

The collection of this information is authorized by O.C.G.A. 45-2-40. This information will be used to determine fitness for

duty and to provide protection to employees from potential harmful effects associated with this employment. Unless otherwise

stated, this information may be disclosed to the hiring agency, State agencies responsible for State benefits and workers’

compensation programs, and, where pertinent, to an appropriate law enforcement agency for investigation for prosecutive

purposes or in a legal proceeding to which the hiring agency is a party. As provided by the Americans with disabilities Act of

1990 (Public Law 101-336), this information is to be filed separately from other personnel records and is to be used only for

legitimate, non-discriminatory hiring and placement purposes with reasonable accommodation, where appropriate. Completion

of this form is voluntary; however, if this information is not provided, the individual may not receive the requested benefits or

employment.

A: Completed by Employee

1. Employee Name: ____________________________________________________ 2.________-_______-_________

Last First Middle Social Security Number

3. Race: _________________ 4. Sex: Female Male 5. ______________ 6. _________________________

Date of Birth Daytime Telephone Number

7. Address: ______________________________________ 8. Position Title: _______________________________

______________________________________________ 9. Position Number: ____________________________

______________________________________________ 10. Location of Position: _________________________

11. Direct Con

tact for Position Information

a. Name:_______________________ f. Dept.: _________________________________________

b. Title:________________________ g. Unit: __________________________________________

c. Telephone: ___________________

h. Add

ress: _____________

_________________________

d. E-Mail: _______________

_______ ______________________________________

e. Fax Number: __________________________ ______________________________________

______________________________________

12. Hav

e you been provided detailed information on the duties of this position?

13. Do you understand the functional requirements and environmental factors of this position?

14. Are you capable of performing the duties and responsibilities of this position (with reasonable

accommodations, if necessary, as described in Section A, Item #17)?

For the following questions, explain a "Yes" answer in the space pr

ovided below

15. Have you ever been employed by the State of Georgia?

16. Have you had a physical examination for employment with the State of Georgia within the past

twelve-month period?

17. Is there anything in your past medical history, of which you have knowledge, that would prevent

you being able to perform the duties of this position?

Yes No

Yes

Yes No

MAPEP 10-51-03 (2006) Page 2

Explanation of items 15-17 checked “Yes.” Enter item number before each comment.

I certify that all information given by me in connection with this medical assessment is true to the best of my

knowledge and belief. I agree and understand that any misstatements of material facts may cause forfeiture

on my part of all right to employment in the service of the State of Georgia; may result in dismissal after

appointment; or may result in loss of entitlement to disability retirement benefits. My signature also indicates

that I understand all of the questions on this form.

18. _____________________________________________________ 19. _____________________________

Signature of Employee Date

B: Completed by Employer

1. Indicate type of job information used for medical review (check all that apply): 2. Check job category:

Job description Other (please specify): Category 1 Sedentary

Performance standards Category 2 Active

Functional requirements analysis Category 3 Food Handling

Environmental factors analysis Category 4 Health-related

Category 5 Law Enforcement

3. Descri

be any notable or unusual job requirements or working conditions: (continue on separate page, if needed)

4. Were any “reasonable accommodations” needed? If “Yes,” describe:

Yes No

. _____________________________________

__________________________

(Type or Print Official Contact’s Name)

6. _________________________________________________________ 7. _____________________________

Signature of Official Contact Date

STATE OF GEORGIA Name: _____________________________________ Soc. Sec. No.: _______-______-________

MEDICAL AND PHYSICAL Job Title: ___________________________________ Department: _________________________

EXAMINATION PROGRAM

MEDICAL HISTORY REPORT Job Category (circle one) 1 2 3 4 5

The purpose of these questions is to gather information concerning your health and physical condition, both now and in the past. This

information will be used only to determine whether you can safely perform the duties of the job for which you are being considered. Please

answer all of the following questions as fully and completely as you can. If you don’t understand a question, or are unsure of how to answer it,

leave it blank and request assistance.

I certify under penalty of perjury, that the information given by me is true to the best of my knowledge and belief. I agree and understand that

any misstatements of material facts may cause forfeiture on my part of all right to employment in the service of the State of Georgia, may result

in dismissal after appointment; or may result in loss of entitlement to disability retirement benefits. My signature also indicates that I

understand all of the questions on this medical history form.

EMPLOYEES’ SIGNATURE: _______________________________________ DATE: ______________________

Individual History – To Be Completed By Applicant/Employee (Use Ink)

A. MEDICAL CONDITIONS. Check every item. Do you have or have you ever had any of the following: (If “Yes,” give date of most

recent occurrence and explain on page 3.)

Health Condition Yes Year No

Health Condition

Yes Year No

HEAD, NOSE, MOUTH AND THROAT

28. Glasses

1. Persistent or severe headaches

29. Contact lenses

2. Frequent nose bleeds

RESPIRATORY SYSTEM (lungs & breathing)

3. Frequent nasal congestion

30. Persistent or severe colds

4. Persistent or severe sinus condition

31. Persistent or severe cough

5. Bleeding gums

32. Coughing blood

6. Persistent or severe dental condition

33. Asthma or breathing difficulty

7. Hoarse when don’t have cold

34. Emphysema

8. Difficulty swallowing

35. Pneumonia

9. Persistent sore throat

36. Tuberculosis

10. Loss of taste or smell 37. Other lung or breathing condition:

11. Head injury

CARDIOVASCULAR SYSTEM (heart & blood vessels)

12. Other head, nose, mouth or throat conditions:

39. Heart attack

EARS AND HEARING

39. Hardening of the arteries (Arteriosclerosis)

13. Hearing difficulties

40 High or low blood pressure

14. Use hearing aid

41. Heart murmur

15. Ringing in ears (tinnitus)

42. Palpitations or irregular heart beat

16. Perforated ear drum

43. Episodes of chest pains, tightness, discomfort

17. Persistent or severe ear infection

44. Shortness of breath

18. Other ear or hearing conditions

45. Varicose veins

EYES AND VISION

46. Swelling of ankles, feet or legs (edema)

19. Glaucoma

47. Leg pains, cramps

20. Cataract

48. Other cardiac conditions:

21. Eye irritations (itching or burning)

GASTROINTESTINAL SYSTEM (stomach & intestines)

22. Eye infection

49. Persistent or severe nausea or indigestion

23. Defective vision

50. Persistent or severe stomach pain

24. Color blindness

51. Vomiting blood

25. Injury to eye

52. Persistent or severe vomiting

26. Eye surgery

53. Hernia (rupture)

27. Double vision

54. Stomach or duodenal ulcer

MS 10-52, February 15, 2005 (Page 1 of 3)

Health Condition Yes Year No Health Condition Yes Year No

55. Colitis

99. Trick or locked knee

56. Hemorrhoids or piles

100. Knee surgery

57. Change in bowel habits

101. Foot problems

58. Black stool or blood in stool

102. Bone infection

59. Persistent or severe constipation

103. Broken or fractured bone

60. Persistent or severe diarrhea

104. Persistent or severe muscle aches or pains

61. Pancreatitis

105. Other Musculoskeletal conditions:

62. Appendicitis

ENDOCRINE/METABOLIC SYSTEM

63. Other conditions of stomach or intestines

106. Diabetes

LIVER, SPLEEN & GALLBLADDER

107. Thyroid condition or disease

64. Cirrhosis

108. Hypoglycemia

65. Hepatitis

109. Unexplained weight gain or loss

66. Yellow jaundice

110. Unusual loss or growth of body hair

67. Gallstones

111. Gout

68. Other conditions of liver, spleen or gallbladder:

112. Osteoporosis or other bone disease:

KIDNEYS & URINARY TRACT

SKIN

69. Kidney stones

113. Rash

70. Kidney infection

114. Hives

71. Blood or pus in urine

115. Moles that bleed or get larger

72. Pain or burning when urinating

116. Change in color of skin (other than suntan)

73. Frequent urination

117. Frequent boils/abscesses

74. Albumen or protein in urine

118. Trouble with fingernails

75. Prostate condition

119. Small itching blisters on the side of fingers or palms

76. Burning discharge from penis

120. Sores that do not heal

77. Other conditions of kidneys or urinary tract

121. Other skin conditions:

REPRODUCTIVE SYSTEM (FEMALES ONLY)

BLOOD/LYMPH (hematologic) SYSTEMS

78. Pregnant at present

122. Anemia

NEUROLOGICAL (Nervous) SYSTEM

123. Bleeding disorder

79. Epilepsy, convulsions, seizures

124 Sickle cell disease or trait

80. Periods of blackouts/loss of consciousness

125. Phlebitis/blood clot

81. Fainting spells

126. Blood transfusion

82. Dizzy spells (vertigo)

127. Chills, fever, night sweats

83. Memory difficulty

128. Lymph node or glandular swelling that persists

84. Tremor of the hands or head 129. Other conditions of blood or lymph:

85. Paralysis of any type

CANCER

86. Stroke

130. Surgery

87. Severe numbness, tingling or weakness

131. Radiation therapy

88. Dyslexia/learning difficulty

132. Chemotherapy

89. Other conditions of neurological (nervous) system:

133. Immunotherapy

MUSCULOSKELETAL SYSTEM

134. Hormone therapy

90. Arthritis

135. Breast

91. Bursitis/tendonitis

136. Bone

92. Swollen or painful joints

137. Skin

93. Dislocations

138. Other

94. Painful or trick shoulder

PSYCHOLOGICAL/MOOD

95. Elbow problems

139. Mental problem requiring hospitalization

96. Wrist or hand problems

140. Suicidal/attempted suicide

97. Back pain

141. Active psychosis

98. Back surgery

142. Drug, narcotic or alcohol

MS 10-52, February 15, 2005 (Page 2 of 3)

Health Condition Yes Year No Health Condition Yes Year No

143. Persistent or severe depression/worry ALLERGIES (caused by)

144. Other psychological conditions: 152. Medication

INFECTIOUS OR CHILDHOOD DISEASES 147. Rheumatic fever

Meningitis/encephalitis 153. Food

146. Polio 154. Soaps or detergents

148. Mumps

155. Pollen

149. Measles

156. Insect bites/scales

150. Venereal Disease

157. Other:

151. Other:

Explanation of items checked “Yes.” Enter item number (1-157) before each comment.

B. CURRENT MEDICATIONS:

C. SURGICA

L HISTORY

Have you ever had surgery? Yes No

[If “Yes, complete the following information about each surgery]

TYPE OF SURGERY DATE (Mo/Yr)

1. __________________________________________ _____________

2. __________________________________________ _____________

D. HOSPITALIZATION HISTORY

Have you ever been hospitalized? Yes No

[If “Yes,” complete the following information about each hospitalization]

REASON FOR HOSPITALIZATION DATE (Mo/Yr)

1. ___________________________________________ ______________

2. ___________________________________________ ______________

3. ___________________________________________ ______________

MS 10-52,

February 15, 2005 (Page 3 of 3)

M E M O R A N D U M

TO: The Examining Physician

FROM: State Personnel Board and

_________________________

(Name of Agency)

DATE:

SUBJECT: Medical and Physical Examination Program (MAPEP)

We earnestly solicit your assistance in completing a medical and physical examination on the bearer.

Medical and physical examinations are of invaluable aid to both the employer and the employee in matching the

physical and working environment demands of the job with the physical and mental capacities of the job candidate.

From a health conservation standpoint, this type of pre-placement examination program is most effective when

aimed at the prevention of occupational disease and injury at work.

The results of the examination should be reported on the enclosed MAPEP “Medical Findings” form (MS 10-56).

All items should be completed by the examining physician except for tests listed in the “Additional Tests Requested”

box at the top of the form. Those items are to be completed when the employing department has indicated that these

tests are needed or if indicated as follow-up to a potential medical condition identified in the physical examination.

Please read the general and specialized standards provided. These standards identify certain assessments that should

receive close attention during the physical examination.

Accompanying this memorandum and the “Medical Findings” form should be several information items and

completed forms, including those indicated below:

__General Information (MAPEP 10-51-03) __General Medical Guidelines

__ Description of Job Duties __Specialized Medical Guidelines

__ Medical History Report (MS 10-52) __Other:

Attached to the “General Information” form (MAPEP 10-51-03) should be information on the duties and

responsibilities of the job for which the bearer is being hired. This information and other job information on form

MAPEP 10-51-03 – specifically, responses to items A.12.-17. and B.3.-4. -- should be carefully considered in

providing your assessment of the medical implication of bearer’s health history and physical condition for the job

duty assignment. (To assist your understanding of item B.2, a more detailed discussion of the job category

description follows on page 2.)

The results of the examination may be reviewed by a medical practitioner selected by the department or under

contract with the state. The responsibility for the final decision on bearer’s employability in the specified positions

rests with the employing department. If further examinations are indicated, the applicant will be notified.

After the examination has been completed, please return all medical materials to the address and employer

representative identified at the bottom of page 2 of the “Medical Findings” form. All forms and materials are to be

sent together, the bearer should not retain any of the documents.

MS 10-55 (Page 1 of 2) Revised May 1, 2017

JOB CATEGORY DESCRIPTIONS

Category 1:

Primarily sedentary, light physical work with limited to no unusual working conditions (e.g.,

Administrative Assistant; Manager, Business Operation; Human Resources Specialist).

Category 2:

Moderate to heavy physical activity and/or moderate to high interface with working conditions

of potential concern for certain health conditions (e.g., Supply/Warehouse Clerk; Housekeeper;

Contracts Administrator; Mechanic).

Category 3:

Positions involving food preparation or the handling of raw consumable animal products (e.g.,

Food Service Worker; Plant Operator; Agriculture Inspector).

Category 4:

Health-related positions involving direct contact with or exposure to airborne or blood-borne

pathogens (e.g., Nurse Manager; Health Aide; Radiologist; Dental Hygienist).

Category 5:

Strenuous physical activity and/or extreme or potentially life-threatening working conditions

requiring a high level of physical capability (e.g., GSP Sergeant; Public Safety Cadet; Special

Agent; Correctional Officer; Fire Prevention Specialist; Conservation Lieutenant).

NOTE: Unless otherwise indicated, expense for all examinations is to be paid by the prospective employee.

MS 10-55 (Page 2 of 2) Revised May 1, 2017

M E M O R A N D U M

TO: The Reviewing Physician

FROM: State Personnel Board and

_____________________

(Name of Agency)

DATE:

SUBJECT: Medical and Physical Examination Program (MAPEP)

We earnestly solicit your assistance in reviewing the attached information and completing an assessment of the

physical fitness of the prospective employee(s) for and position(s) listed below.

Information relating to the medical and physical condition of prospective employee is of invaluable aid to both the

employer and the employee in matching the physical and working environment demands of the job with the physical

and mental capabilities of the job candidate. From a health conservation standpoint, this type of pre-placement

program is most effective when aimed at the prevention of occupational disease and injury at work.

The results of the assessment should be reported on the enclosed “Report to Employing Agency” form (MS 10-57).

Please review the standards provided, these standards identify certain assessments that should receive close attention

during your review.

Accompanying this memorandum and the “Report to Employing Agency” form, should be several information items

and completed forms, including those indicated below:

__General Information (MAPEP 10-51-03) __General Medical Guidelines

__ Description of Job Duties __Specialized Medical Guidelines

__ Medical History Report (MS 10-52) __Other: ________________________

MS 10-55-A (Page 1 of 2) Revised May 1, 2017

Information on the duties and responsibilities of the job for which the prospective employee is being hired should be

included in section A and B of the “General Information” form (MAPEP 10-51-03). Additional job information may

also be attached. Please consider this information as you provide your assessment of the medical implications of the

prospective employee’s health history and physical condition for job duty assignment. (To assist your understanding

of item B.2., a more detailed discussion of the job category description follows.) Your medical opinion will be

invaluable to the employing department, in as much as, the responsibility for the final employability decision in the

specified position rests with the employing department.

After your review has been completed, please return all medical materials to the address and employer representative

identified in section A, item 11 of the “General Information” form (MAPEP 10-51-03).

JOB CATEGORY DESCRIPTIONS

Category 1:

Primarily sedentary, light physical work with limited to no unusual working conditions (e.g.,

Administrative Assistant; Manager, Business Operation; Human Resources Specialist).

Category 2:

Moderate to heavy physical activity and/or moderate to high interface with working conditions

of potential concern for certain health conditions (e.g., Supply/Warehouse Clerk; Housekeeper;

Contracts Administrator; Mechanic).

Category 3:

Positions involving food preparation or the handling of raw consumable animal products (e.g.,

Food Service Worker; Plant Operator; Agriculture Inspector).

Category 4:

Health-related positions involving direct contact with or exposure to airborne or blood-borne

pathogens (e.g., Nurse Manager; Health Aide; Radiologist; Dental Hygienist).

Category 5:

Strenuous physical activity and/or extreme or potentially life-threatening working conditions

requiring a high level of physical (e.g., GSP Sergeant; Public Safety Cadet; Special Agent;

Correctional Officer; Fire Prevention Specialist; Conservation Lieutenant).

MS 10-55-A (Page 2 of 2) Revised May 1, 2017

STATE OF GEORGIA

MEDICAL AND PHYSICAL

EXAMINATION PROGRAM

edical Findings

Examinee’s Name

SSN 3. Height (Feet, Inches) 4.

eight (pounds)

5. Vision Evaluation

Depth Perception Within Normal Limits

Yes  No 

Peripheral Vision

Right Eye ________ Left Eye ________

istant Vision

Near Vision

Without Glasses 

Right 20/ Left 20/ ______

ithout Glasses

□ Right 20/ _____ Left 20/ _____

With Glasses 

Right 20/ Left 20/ ______

With Glasses

□ Right 20/ _____ Left 20/ _____

e. Is color vision normal when Ishihara or other color plate test is used?

Yes No

f. If the answer is “No”, can applicant pass lantern or other

compatible?

Yes No

6. Hearing Evaluation

a. OTOSCOPIC EXAMINATION: Right Ear _______ Left Ear ______

b. PURE TONE AIR CONDUCTION TEST RESULTS: (This section is to be used for all pre employment air conduction hearing testing.)

Right Ear

Left Ear

250 500 1000 2000 3000 4000 6000 8000 250 500 1000 2000 3000 4000 6000 8000

c. SOUND FIELD PURE TONE/WARBLE TONE TEST RESULTS: (This section is to be used in conjunction with the pure tone air conduction testing

section for all individuals with hearing aids who do not meet the guidelines on the air conduction test.)

250

500

1000

2000

3000

4000

6000

8000

Sound Field Test

If individual meets the stated hearing guideline, no further hearing testing is necessary for the purpose of employment. However, if any single air conduction

threshold is obtained outside the normal, 0-24dB range, the results of the test must be explained to the candidate and the recommendation made to obtain a

complete audiological evaluation at the individual’s expense.

d. AUDIOMETER SERIAL #: ______________________ e. DATE OF CALIBRATION: _______________________

f. MEETS HEARING GUIDELINES: Yes No

STRICTED/MEDICAL

ADDITIONAL TEST(S) REQUESTED

Urinalysis

Pulmonary Function

Tuberculin Skin Test (TST)

EKG/Resting

EKG/Stress

Hemoglobin/Hematocrit

Chest X-Ray

Back X-Ray

Other Tests

NOTE TO EXAMINING PHYSICIAN

The person you are about to examine is being

evaluated for the position described in job

materials provided. In conducting your exam and

reporting your findings and conclusions, take the

job duty data into consideration.

ALL FIELDS IN THIS FORM MUST

BE FILLED IN OR THE

REVIEWING PHYSICIAN WILL

RETURN THE FORM TO YOU.

MS 10-56, May 4, 2012 (Page 1 of 3)

7. Blood Pressure/Pulse

a. Systolic/diastolic b. Two additional Readings if elevated c. Pulse

8. Physical Examination

Clinical Evaluation Normal Abnormal Remarks

a. Head, face, neck, and scalp

b. Nose

c. Mouth and Throat

d. Ears

e. Eyes

f. Ophthalmoscopic

g. Ocular motility

h. Lungs and Chest (Breast, if

indicated)

i. Heart

j. Vascular system (Varicosities, etc.)

k. Abdomen

l. Anus and rectum (If indicated)

m. Endocrine system

n. Hernia (Any type)

o. Upper extremities

p. Feet

q. Lower extremities

r. Spine

s. Identifying body marks, scars

t. Skin, lymphatics

u. Neurological

v. Mental status

9. Allergies

1. 3.

2. 4.

10. Surgery

Type of Surgery Date (Mo/Yr)

RESTRICTED/MEDICAL

MS 10-56, May 4, 2012 (Page 2 of 3)

11. Comments/Implications for Fitness for Duty

12. Physician Signature and Address

a. Physician's Name (Type or Print) b. Physician Telephone c. Address

d. Signature e. Date

13. Employer Name and Address

IMPORTANT: Examining Physician --

Return all materials supplied by the

prospective employee to the employer

address provided.

eturn to:

n order to comply with ‘‘The Genetic Information Nondiscrimination Act of 2008 (GINA), we ask

that you NOT provide any genetic information when responding to this request for medical

information. This includes family medical history, results of genetic tests, information regarding

genetic services, and genetic information about an individual’s or family members’ fetus or

embryo.

MS 10-56, May 4, 2012 (Page 3 of 3)

RESTRICTED/MEDICAL

MEDICAL EXAMINATION

REPORT TO EMPLOYING AGENCY

M E M O R A N D U M

TO:

_____________________________________________

(Employing Agency)

__________________________________________

(

Address)

FROM: _____________________________________________

(

Name)

__________________________________________

(

Address)

__________________________________________

(

Address)

In reviewing the medical information/examination of , for a _______________________________________________

(Name of Applicant)

position and performed on by _______________________________, M.D., of ____________________________________,

(Date) (Name) (Address)

The physical demands of the position and the working conditions under which work is performed as approved by the State Personnel Board and

described in the procedure manual, have been compared with the health status of said prospective employee and the following report is submitted

for your consideration:

Physically capable to meet the demands of position with:

) No limitations (

)

) Moderate limitations (not to be transferred to another position without review of medical records)

( )

_________________________________________________________________________________________________

______________

__________________________________________________________________________________________________________________

2. Recommend further examinations: _______________________________________________________________________________________

Remarks: _________________________________________________________________________________________

________________

oes not meet the physical standards of the position: _______________________________________________________________________

___________________________________________________________________________________________________________________

Inc

omplete or inadequate information: ___________________________________________________________________________________

Date: _______________________ M.D.

(Reviewing Physician)

MS 10-57, February 15, 2005

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 33

VII. APPENDICES

 APPENDI

X A – O.C.G.A. 45-2-40 – Medical and Physical Examination of Prospecti

State Employees

 APPENDI

X B – SPB 478-4 –Medical and Physical Examination Program

 APPENDIX C – Worksheet of Functional Requi

rements

 APPENDI

X D – O.C.G.A. 34-9-368 – Subsequent Injury Tr

ust Fund

 APPENDI

X E – Glossar

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 34

APPENDIX A

Medical and Physical Examination of Prospective State Employees

O.C.G.A. 45-2-40

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 35

Medical and Physical Examination of Prospective State Employees

O.C.G.A. 45-2

45-2-40

No person who is otherwise qualified shall be employed in any capacity by the state or any

department or agency thereof unless the person is certified as meeting the standards of medical

and physical fitness by a qualified medical practitioner within a prescribed number of calendar

days after the date of an offer of employment. However, the State Personnel Board may provide

for standards of medical and physical fitness for some positions that require only certification by

the prospective employee and such certification may be accepted by the respective employing

department without further assessment by a medical practitioner.

45-2-41.

(a) The commissioner of administrative services, subject to the approval of the State Personnel

Board, shall appoint up to five doctors of medicine licensed by the state and other specialists, as

appropriate, to develop standards of medical and physical fitness required for persons about to be

appointed to positions in the state service. Such standards shall be related to the duties required

of specific positions in the state service. The commissioner of administrative services shall

develop the forms to secure the information needed to determine if prospective employees meet

the medical and physical fitness standards required to perform the essential functions of the

relevant position.

(b) If a physical examination is required by the standards of medical and physical fitness, a

licensed medical practitioner may perform the assessment and report the findings to a physician

in the employ of or under contract with the state or respective employing department. The

licensed medical practitioner may be of the applicant's choice and at the applicant's expense or

may be a licensed physician in the employ of or under contract with the state or respective

employing department. When the licensed physician is in the employ of or under contract with

the state or respective employing department, the assessment and findings shall be made to the

respective department and shall be final, except as provided in the State Personnel Board rules.

enter into an agreement on behalf of the departments to contract with medical practitioners for

the purpose of conducting assessments for medical and physical fitness as required by the

standards of medical and physical fitness. In such case, each department may use the selected

contractor as an expense of a departmental employee selection process or may recommend that

prospective employees seek the examination at the contractor's site at the prospective employee's

expense. If the prospective employee chooses to use a medical practitioner other than one

selected by the department or under contract with the state on behalf of the department, the

findings and recommendations of such other practitioner shall be furnished to the medical

practitioner selected by the department or under contract with the state on behalf of the

department for final determination of the medical and physical fitness of the prospective

Appendix A (Page 1 of 3)

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 36

employee. Expenses for the medical practitioner under contract with the state on behalf of the

department shall be paid by the respective employing department based upon the services

provided by such medical practitioner.

(d) The State Personnel Board is authorized to establish a fee and make payment of same to the

consultants appointed by the commissioner of administrative services for services rendered in the

development of standards of medical and physical fitness for state employees; provided,

however, that no state employee shall receive additional compensation for services as a

consultant for developing the standards of medical and physical fitness.

(e) The certification required by Code Section 45-2-40 shall be completed as required in the rules

of the State Personnel Board; provided, however, that if a physical examination is required by

the standards for medical and physical fitness, the physical examination shall be completed prior

to the date of appointment, and the reporting of results shall occur within a prescribed number of

calendar days from the date of appointment.

45-2-42.

The state department or agency shall furnish to the applicant the standards of medical and

physical fitness for the position for which applied in such manner as to enable a medical

practitioner to ascertain the physical capacity of the applicant to fulfill the requirements of

employment.

45-2-43.

If a physical examination is required, the examining medical practitioner shall make a report

certifying that the prospective employee has been examined and certified as not having any

condition that would impair the fulfillment of the prescribed duties of the employment. However,

if a condition exists which would impair the fulfillment of the prescribed duties, the medical

practitioner shall identify such condition, the employing agency shall provide reasonable

accommodation to the extent required by the Americans with Disabilities Act, 42 U.S.C. Section

12101, et seq., and the medical practitioner shall certify that the prospective employee, with the

accommodation, meets the standards of medical and physical fitness for the position. Additional

confidential medical information should be given only with the consent of the applicant. The

examining medical practitioner shall complete the necessary forms and findings in accordance

with the rules of the State Personnel Board. All such medical information shall be retained in a

separate, confidential file and not as a part of the personnel file.

45-2-44.

The State Personnel Board, subject to the approval of the Governor, shall adopt and promulgate

rules and regulations for the administration of this article. The board, through the commissioner

of administrative services, is authorized to expend allocated funds for the necessary forms and

other incidental administrative expenses in effectuating this article. All other expenses shall be

borne by the prospective employee or the respective employing department in accordance with

the rules of the board.

Appendix A (Page 2 of 3)

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 37

45-2-45.

This article shall not apply to department heads, temporary employees, other categories of

employees of the state as defined by the State Personnel Board, or to students in the University

System of Georgia in the employ of the state, nor shall it apply to any present employee. As used

in this Code section, the term "temporary employee" means a person whose period of

employment is of short duration or is part time as defined by the State Personnel Board.

Appendix A (Page 3 of 3)

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 38

APPENDIX B

Rules of the State Personnel Board

Governing the Medical and Physical

Examination Program

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 39

RULES OF THE STATE PERSONNEL BOARD

CHAPTER 478-4

MEDICAL AND PHYSICAL EXAMINATION PROGRAM

478-4-.01 Definitions.

(1) Co

mmissioner and Commissioner of Administrative Services are synonym

ous and mean the chief

executive officer of the

State Department of Administrative Services. The term also includes any

person properly designated by the Commissioner to perform any duty of the Com

missioner under

these rules. (10-31-96/1-3

-97)

(2) Committee and

Medical and Physical Standards Committee are synonymous and mean the bod

appointed b

y the Commissioner to advise the Board relative to standards of medical and ph

ysical

fitness. (10-3

1-96/1-31-97)

(3) Department means any department or agency of the state. (10-31-96/1-31-97)

(4)

Prospective Employee m

eans any person, other than a department head, who has

been offered

ployment by any state department, who will work at least 30 hours per week, and whose

employment shall not be of short-term, temporary, contingent, interm

ittent, part-time, or student

nature. (10-31-96/1-31-97)

(5)

Qualified medical practitioner

means any medically trained person who

is licensed to assess the

edical and physical condition of a Prospective Employee. (10-31-96/1-31

-97)

(6)

State Personnel Board and Board are synonymous and mean the body established by Article IV,

Section III of the Constitution of the State of Georgia. (10-31-96/1-31-97)

(7)

State Ph

ysician means any licensed physician who has been employed or contracted by

departm

ent or the Commissioner for the purpose of conducting Limited or

Full Physical

Examinations, assessing the results of the examination for Prospective Employees, or determining if

the Prospecti

ve Employee meets the standards of physical fitness for the specific position. (10-31-

96/1-31-97)

Authority O.C.G.A. Sec. 45-2-40. History. Original Rule entitled “Definitions” adopted. F. Feb. 7, 1997; eff

Jan. 31, 1997, as specified by the Board.

478-4-.02 General Provisions.

(

Applicability. No Prospective Employee who is otherwise qualified shall be employ

ed on and

after Jul

y 1, 1996, in any capacity by the state or any department or agency thereof, unless the person

has completed certification or is certified by a qualified medical practitioner as meeting th

e standards

of m

edical and physical fitness as established by the Board. (10-31-96/1-31-97

)

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 40

(2) Records. All medical information that is completed or collected in any form about a Prospective

Employee under the Medical and Examination program shall be confidential and retained separately

from other personnel records of the employee. (10-31-96/1-31

-97)

(3)

Prospect

ive Employee’s Responsibility. A Prospective Employee may choose to use a me

dical

practitioner other than a State Physician to complete the Limited or Full Physical Examination. The

Prospective Employee shall cause the physical examination report to be forwarde

d to a State

ysician to determine if the appropriate standards of physical fitness have been met. (10-31-96/1-

31-97)

(4)

Completion of the Physical Examination and Certification. The Prospective Employee shall

com

plete the self-assessment or the Limited or Full Physical Examination prior to the effective date

of employment. The employing department shall require the Prospective Employee who chooses to

use a medical practitioner other than a State Physician to submit the Limited or

Full Physical

Exam

ination assessment to the employing department prior to the date the employee reports to work.

The employing department and the Commissioner shall provide for performance requirements that

stipulate that a State Physician shall complete the assessment and decision no later than the fortieth

day following receipt of the Physical Examination report or conducting the Limited or Full Physical

Examination. (10-31-96/1-

31-97)

478-4-.03 Organization.

(1)

Functions, Duties and Responsibi

lities of the State Personnel Board. The State Personnel Board

shall prescribe the general policies by which the Medical and Physical Examination Program shall be

administered. Specific functions of the Board are: (10-31-96

/1-31-97)

(a) subject to the approval of the Governor, pro

mulgate rules and regulations for the effective

adm

inistration of the Medical and Physical Examination Program; (10-31-96/1

-31-97)

(b) after providing interested parties an opportunity

to review and comment,

approve the

standards o

f medical and physical fitness that are required by the duties of

the specific positions

in the state service; (10-31-96/1-31-97)

a fee to be paid to consultants for services rendered in the developm

ent of standards

of m

edical and physical fitness; however, persons in the employ of the st

ate shall not receive

com

pensation other than the regular salary paid by the employing department or agency. (10-31-

96/1-31-97)

(2)

Functions,

Duties and Responsibilities of the Commissioner. The Commissioner shall administe

the m

edical and physical examination and certification program. The Commis

sioner:

(a) subject to the approv

al of the State Personnel Board, shall appoint a Medical and Physical

Standards C

ommittee consisting of up to five Georgia licensed doctors of me

dicine or other

specialists to develop stan

dards of medical and physical fitness; (10-31-96/1-31

-97)

(b) shall dev

elop all forms for administration of the medical and physical examination program,

shall develop procedural processes for administration and shall publish the standards for medical

and ph

ysical fitness; (10-31-96/1-31-97)

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 41

enter into an agreem

ent on behalf of the departments to conduct assessments for medical and

physical fitness as required by the standards of medical and physical fitness; (10-31-96/1-

31-97)

(d) provide technical assistance to employ

ing departments for complying with the requirements

of the Medical and Physical Examination Program. (10-31-96/1-31-97)

(3)

Functions, Duties,

and Responsibilities of the Employing Departments. The department head or

his or her designee shall administer the medical and physical examination and certificatio

n within the

respective departm

ent in compliance with the standards of medical and physical fitness.

In addition,

the department head or his or her designee: (10-31-96/1-31-97)

(a) shall develop policies and processes necessary for compliance with these rules

within 120

calendar days of the effec

tive date of these provisions; (10-31-9

6/1-31-97)

(b) shall advise the Co

mmissioner and Committee on duties required for specific positions in the

respective departm

ent; (10-31-96/1-31-

97)

ay employ a licensed physician or contract for services of a licensed ph

ysician to be

designated as a State Physician to perform

the assessment and make

a determination as to

compliance with the standards of physical fitness for Prospective Employees of the respective

department; (10-31-96

/1-31-97)

(d) m

ay utilize the statewide contract of State Physician(s) to conduct the Limited or Full

Physical Examination and to determine if the Prospective Employee meets the a

ppropriate

standards for physical fitness for the specific position; (10-31-96/1-31-97)

(e) may pay the charge for contract services of the State Physician to conduct the Limited

or Full

ysical Examination for the specific position; (10-31-96/1-31-9

(f) shall pa

y any charges for contract services for the State Physician to review Limited or Full

Physical Examination reports and decide if the Prospective Employee’s physical condition meets

the standards of physical fitness for the specific posi

tion; (10-31-96/1-31-97)

(g) shall inform

the Prospective Employee of the administrative requirements to comply with the

Medical and Physical Examination Program and furnish the Prospective Employee with the

appropriate form

s and standards of medical and

physical fitness for the position for which the

ployment offer has been made. (10-31-96/1-31-9

Authority O.C.G.A. Sec. 45-2-40. History. Original Rule entitled “Organization” adopted. F. Feb. 7, 1997; eff

Jan. 31, 1997, as specified by the Board.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 42

478-4-.04 Standards of Medical and Physical Fitness.

(1) The Com

missioner shall determine the most appropriate method of collecting information about

the duties required of specific positions and shall provide the Committee with departmental collected

information that describes the essential functions of specific groups of positions. (10-31-9

6/1-31-97)

(2) Ba

sed upon the information about the essential job functions, comments from departmental

representatives, and guid

elines provided in state and federal laws, the committee shall form

ulate

recomm

ended standards for medical and physical fitness for specific positions. The standards fo

edical and physical fitness that are in effect on June 30, 1996 shall remain in effect until modified

through these rules. (10-31-96/1-31-97)

(3) Upon ap

proval by the Board of new or revised standards, Prospective Employees wh

o are

ployed on and after the effective date of the new or revised standards of medical and physical

fitness shall be assessed using the new or revised standards. The standards shall include the me

thod

of assessm

ent and certification that is required for a decision as to the medical and physical fitness of

the Prospective Employee. (10-31-96/1-31-97)

Authority O.C.G.A. Sec. 45-2-40. History. Original Rule entitled “Standards of Medical and Physical Fitness”

adopted. F. Feb. 7, 1997; eff. Jan. 31, 1997, as specified by the Board.

478-4-.05 Assessment and Certification.

(1) Self-Asse

ssment. Positions that require general health conditions may

be included in general

standards of m

edical and physical fitness that provides for the Prospective Employ

ee to assess

oneself b

y completing a questionnaire or statement form. (10-31-96/1-31-97

)

(2)

Limited Physical Examination. Positions having essential functions that may involve moderate to

heavy physical activity or exposure to conditions that normally place the employee or public in

unhealthy risk situations may require a Limited Physical Examination for assessing if the Pros

pective

ployee meets the appropriate standards of medical and physical fitness. The examination may

perform

ed by a State Physician; however, the employee may choose to use any licensed me

dical

practitioner other than a State Physician who is designated by the employing department. (10-31-

96/1-31-97)

(3)

Full Phy

sical Examination. Prospective Employees for positions having essential f

unctions that

require stre

nuous physical activity or potentially life-threatening working conditions shall be

assessed by a Full Physical Examination. The examination may be performed by a State Physician;

however, the employee may choose to use an

y licensed medical practitioner other than a State

ysician who is designated by the employing department. (10-31-96/1-31-

97)

(4)

Certification. Certification that the Prospective Employee meets the standards of medical and

physical fitness may be completed by the Prospective Employee or a State Physician. (10-31-96/ 1-

31-97)

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 43

(a) A department may accept the self-assessment as self-certification that the individual meets the

general standards of medical and physical fitness to perform the essential functions of a position

for which the general standards apply; however, the department may refer the form of self-

assessment and the essential functions required of the Prospective Employee to a State Physician

for assessment and certification that the Prospective Employee meets the standards of me

dical

and physical fitness to perform the essential functions of the position. (10-31-96/1-31-97)

(b) A department may accept the results of the Limited Physical Examination or Full

Physical

Exam

ination and statement of assessment by a State Physician that the Prospective Employ

eets the standards of medical and physical fitness to perform the essential functions of the

specific position. (10-31-96/1-31-97)

Physical Examination or Full Physical Examination report by a medical practitioner oth

er than a

State Physician. Based upon the report and any

additional information required to ma

ke an

assessment, a State Physician shall make an assessment of the results and determine if the

Prospective Employee may be certified as meeting the standards of medical and ph

ysical fitness

to perform

the essential functions of the specific position. (10-31-96/1-31-97)

(5) Cost.

A department may develop a written policy that establishes the c

onditions under which the

department or the Prospective Employee must pay the cost of a Limited or Full Physical

Exam

ination. (10-31-96/1-

31-97)

(a)

Depa

rtment Pay. The respective department may use appropriated funds for payment to pay a

State Physician for performing the Limited or Full Physical Examination and certification. (10-

31-96/1-31-97)

(b)

mployee Pay. The respective employing department may develop or participate in a pricing

arrangement by which the State Physician may charge the Prospective Employee for a Limi

ted or

Full Ph

ysical Examination and certification. (10-31-96/1-31-97

)

(c)

Employee Pay. When a Prospect

ive Employee chooses to use a medical practitioner other

than a State Physician, the employee shall pay the charge made by the medical practitioner. (10-

31-96/1-31-9

(6)

Reasonable Accommodations. A department shall provide reasonable accommodation to the

extent required by the Americans with Disabilities Act, 42 U.S.C. Sect 12010 et seq. The departme

shall take into considerati

on the report from the examining medical practitioner that the

Prospective

ployee does not have any condition that would impair the fulfillment of

the prescribed duties of

the position and the certification statement of a State Physician when com

ply

ing with the

requirements of federal and state law. (10-31-96/1-3 1-97)

Authority O.C.G.A. Sec. 45-2-40. History. Original Rule entitled “Assessment and Certification” adopted. F.

Feb. 7, 1997; eff. Jan. 31, 1997, as specified by the Board.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 44

478-4-.06 Appeal.

(1) Depa

rtmental Policy. Each department shall establish a written policy that provides the

department with an informed opinion when Prospective Employees subm

it an appeal, regardless of

the form

at under which presented, contesting any requirement of the Medical and Physical

Examination Program. (10-31-96/1-31-

97)

(2)

Departmental Decision

. Upon receipt of an appeal from a Prospective Employee, the employing

department shall review the facts and circumstances, obtain an informed o

pinion, and issue a final

adm

inistrative decision to dispose of the appeal. (10-31-96/1-31

-97)

(3)

Notice to Commissioner. A department shall provide to the Commissioner notification of any

appeal or litigation filed in any court by a Prospective Employ

ee that alleges a violation of these

rules. When

a decision regarding the issue is rendered by the appropriate departme

ntal official or

court, a cop

y of the decision shall also be made available to the Commissioner. (10-31-96

/1-31-97)

Authority O.C.GA. Sec. 45-2-40. History. Original Rule entitled “Appeal” adopted. F. Feb. 7, 1997; eff. Jan.

31, 1997, as specified by the Board.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 45

APPENDIX C

Worksheet of Functional Requirements and

Environmental Factors

(MS 10-59)

C. JOB FUNCTIONS

List and briefly describe major functions of the job.

List in order of importance, most important first.

For each function, indicate percentage of time spent and answer ‘yes

or no’ to the ten questions provided. (NOTE: The response to

question ) is a decision about “essential” functions under ADA.)

For “essential” functions, identify equipment, machinery or vehicle

required to performance

Indicates the % of total annual work time

typically spent on this function.

a. Does this function need to be done at all?

b. At this time, is the incumbent of this position

the only staff member to whom this function

can be assigned?

c. Would eliminating this function

fundamentally change the job?

d. Does this job exist primarily to do

this function?

e. Is special expetise/judgement required?

f. Is special training or education required?

g. Is a license required?

h. Would there be any significant consequence

if this is not done?

i. Did the previous incumbent of the position

do this?

j. Is this function “essential”? (NOTE: Use

ADA definition. The more ‘yes’ responses a-I,

the stronger the support for “essential.)

For each

“essential”

functional list

any equipment,

machinery, or

vehicles required

to perform the

function.

MS 10-59 (Attach additional sheets, if needed.)

Appendix C

D. ESSENTIAL FUNCTIONAL (PHYSICAL) REQUIREMENTS AND ENVIRONMENTAL FACTORS:

Circle the number preceding each functional requirement and each environmental factor involved in the performance of the essential

functions marked in section C on the previous page. For circled items, indicate frequency by checking the appropriate box for Occasional

(<25%), Frequent (25-75%) or Continuous (75% +)

Functional Requirements Environmental Factors

Occasional Frequent Continuous Occasional Frequent Continuous

(<25%) (25-75%) (75% +) (<25%) (25-75%) (75% +)

1. Heavy lifting, 45 pounds and over   

2. Moderate lifting, 15-44 pounds   

3. Light lifting, under 15 pounds   

4. Heavy carrying, 45 pounds and over   

5. Moderate carrying, 15-44 pounds   

6. Light carrying, under 15 pounds   

7. Straight pulling   

8. Pulling hand over hand   

9. Pushing   

10. Reaching above shoulder   

11. Use of fingers(e.g., typing)   

12. Both hands required or compensated by the use

of acceptable prostheses   

13. Extended sitting   

14. Running   

15. Walking   

16. Standing   

17. Crawling   

18. Kneeling   

19. Repeated bending   

20. Climbing, legs only   

21. Climbing, use of legs and arms   

22. Operation of crane, truck, tractor, or motor vehicle   

23. Ability for rapid mental and muscular

coordination simultaneously   

24. Minimal visual requirements (e.g., shapes,

shadows, contrasts)   

25. Routine visual requirements (e.g., reading with

attention to details; seeing activities near and far)   

26. Acute visual requirements (e.g., microscopic work,

high speed driving)   

27. Night vision   

28. Peripheral vision   

29. Depth perception   

30. Ability to distinguish basic colors   

31. Ability to distinguish shades of colors   

32. Ability to smell   

33. Minimal hearing ability (e.g., loud noises,

emergency sirens)   

34. Routine hearing ability, (e.g., whispers at close range,

voices at 15 feet, converse by telephone)   

35. Acute hearing ability (e.g., use of stethoscope,

radio transmission with static)   

1. Inside   

2. Outside   

3. Excessive heat   

4. Excessive cold

 



5. Excessive humidity   

6. Excessive dampness or chilling   

7. Dry atmospheric conditions   

8. Excessive noise   

9. Dust   

10. Fumes, smoke, or gases   

11. Silica, asbestos, etc.   

12. Solvents (degreasing agents)   

13. Grease and oils   

14. Acidic/caustic solutions   

15. Pesticides   

16. Other chemicals (specify)

_________________________________________________   

17. Human blood, body fluids, or tissue   

18. Human wastes   

19. Animal blood, body fluids, or tissue   

20. Animal wastes   

21. Biological agents   

22. Biomedical waste   

23. Radiant energy   

24. Electrical energy   

25. Slippery or uneven walking surfaces   

26. Working around machinery with moving parts   

27. Working around moving objects or vehicles   

28. Working on ladders or scaffolding   

29. Working below ground   

30. Working with sharp instruments   

31. Working with fire, boilers, large hot stoves or the like   

32. Unusual fatigue factors (specify)

_________________________________________________   

33. Cleaning supplies/abrasives   

34. Working with hands in water   

35. Explosives   

36. Combustibles   

37. Vibration   

38. Working closely with others   

39. Working alone   

40. Protracted or irregular hours of work   

41. Other (specify)

_________________________________________________   

MS 10-59

Appendix C

E. ESSENTIAL FUNCTIONAL

COGNITIVE REQUIREMENTS:

F. ESSENTIAL FUNCTIONAL

MATHEMATICS REQUIREMENTS:

G. ESSENTIAL FUNCTIONAL

COMMUNICATION REQUIREMENT

SPEECH:

Circle the number for the highest level of cognitive skills needed to perform any of the "essential" functions marked in

Section C on page 1.

Circle the number for the highest level of mathematics skills needed to perform

any of the "essential" functions marked

in Section C on page 1.

Circle the number for the highest level

of speech communication needed to

perform any of the essential functions

marked in Section C on page 1.

1. Apply common sense understanding to carry

out simple one- or two-step instructions. Deal

with standardized situations with occasional or

no variables in or from these situations

encountered on the job.

2. Apply common sense understanding to carry

out detailed but uninvolved written or oral

instructions. Deal with problems involving a

few concrete variables in or from standardized

situations.

3. Apply common sense understanding to carry

out instructions furnished in written, oral, or

diagrammatic form. Deal with problems

involving several concrete variables in or from

standardized situations.

4. Apply principles of rational systems to solve

practical problems and deal with a variety of

concrete variables in situations where only

limited standardization exists. Interpret a

variety of instructions furnished in written, oral,

diagrammatic, or schedule form.

5. Apply principles of logical or scientific thinking

to define problems, collect data, establish facts,

and draw valid conclusions. Interpret an

extensive variety of technical instructions, in

books, manuals, and mathematical or

diagrammatic form. Deal with several abstract

and concrete variables.

6. Apply principles of logical or scientific thinking

to a wide range of intellectual and practical

problems. Deal with non-verbal symbolism

(formulas, scientific equations, graphs, musical

notes, etc.) in its most difficult phases. Deal

with a variety of abstract and concrete variables.

Comprehend complex, hard-to-understand

concepts.

1. No mathematics requirement.

2. Perform simple addition and subtraction,

reading and copying of figures, or counting

and recording.

3. Use arithmetic to add, subtract, multiply,

and divide whole numbers.

4. Make arithmetic calculations involving

fractions, decimals and percentages.

5. Perform ordinary arithmetic, algebraic, and

geometric procedures in standard, practical

applications.

6. Apply knowledge of advanced mathematical

and statistical techniques such as differential

and integral calculus, factor analysis, and

probability determination, or work with a wide

variety of theoretical mathematical concepts

and make original applications of

mathematical procedures, as in empirical and

differential equations.

1. No speech requirement.

2. Expression of a level to verbally respond to

supervisors or co-workers in the affirmative or

negative.

3. Expression of a level to respond to or make basic

requests. Vocalization to alert others to

emergencies. Capable of basic verbal exchange,

though may not be able to communicate by

telephone .

4. Expression of a level to communicate verbally with

clients/customers and others to obtain and provide

basic information. Able to communicate by

telephone. Capable of explaining routine policies

and of properly referring more complex cases.

5. Expression of a level to communicate fluently with

clients/customers and others to obtain and provide

complex information. Vocalize and explain detailed

data and problem-solve, both in-person and by

telephone. Capable of interpretation of technical

materials, oral presentation of reports and able to

adapt vocabulary, tone and content for listener.

6. Expression of a level comparable to 5, plus highest

order verbal skills such as ability to lecture to large

groups, ability to speak on complex issues without

prepared notes.

MS 10-59

Appendix C

H. ESSENTIAL FUNCTIONAL

COMMUNICATION REQUIREMENT-COMPOSITION

I. TRAVEL REQUIREMENTS

Circle the number for the highest level of composition ability needed to perform

any of the essential functions marked in Section C on page 1.

Circle the number for the highest level of travel needed to perform any of the

essential functions marked in Section C on page 1.

1. No composition requirement

2. Comprehension and expression of a level to record very limited

information such as name and address of client/customer.

3. Comprehension and expression of a level to record fairly uncomplicated

information frequently such as filling in report forms, logging entries and

taking telephone messages.

4. Comprehension and expression of a level to routinely draft narrative

information such as case histories, compose routine correspondence on

own initiative, make interview notes. May involve a large volume of such

composition.

5. Comprehension and expression of a level to draft lengthy technical

documents such as project or research reports, policy position papers and

other advanced informational materials requiring grammatical correctness

and clarity of expression. Requires facility to compose narrative text and

technical data that may vary according to the intended audience. May

involve a large volume of such composition.

1. No travel required.

2. Minimal travel required - ability to travel infrequently (i.e., annually) for

activities such as developmental sessions at a centralized training center.

3. Moderate travel required - ability to travel occasionally (i.e., quarterly) for

activities such as out-of-town meetings or training sessions.

4. Normal travel required - ability to travel frequently (i.e., weekly-monthly) for

activities such as home visits, collateral contacts, transport of clients to

appointments, delivering mail, auditing records, inspecting facilities, or other

activities requiring frequent travel under normal conditions.

5. Extreme travel required - ability to travel routinely (i.e., daily) under extreme

conditions such as all hours of day/night in high risk/dangerous settings such

as to remove and place children in protective custody or heavy travel for long

distances such as conducting business sessions in various parts of the state or

nation.

6. Comprehension and expression of a level comparable to 5, plus highest

order of composition skills such as ability to do this as primary function of

the job, to draft and edit publication-quality papers, to prepare highly

complex documents such as wills and contracts. May involve a large

volume of such composition.

J. OTHER SPECIAL DEMANDS: List and explain any other special

requirements of the position necessary to perform the essential job functions

identified in Section C on page 1.

Reviewer’s Name Date

Position

Reviewer's Signature

_________________________________________________________________________________

MS 10-59

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 50

APPENDIX D

Dissolution of Subsequent Injury Trust Fund

O.C.G.A.

34-9-368

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 51

34-9-368.

(a) The Subsequent Injury Trust Fund shall not reimburse a self-insured employer or an

insurer for a subsequent injury for which a claim is made for an injury occurring after June 30,

2006. The Subsequent Injury Trust Fund shall continue to reimburse self-insured employers or

insurers for claims for injuries occurring on and prior to June 30, 2006, which qualify for

reimbursement.

(b) Self-insured employers and insurers shall continue to pay assessments pursuant to Code

Section 34-9-358 to the extent necessary to fund claims for injuries occurring on and prior to

June 30, 2006.

which claims are filed for injuries occurring on and prior to June 30, 2006, the board of trustees

shall adopt and implement resolutions providing for the final dissolution of the Subsequent

Injury Trust Fund. Such resolutions shall become effective when all claims made for injuries

occurring on and prior to June 30, 2006, have been fully paid or otherwise resolved and shall

include provisions for:

(1) The termination of assessments against insurers or self-insurers;

(2) The pro rata refund of assessments previously collected and unexpended;

(3) The termination of employment of the employees of the fund or the transfer of

employment of any employees to any other state agency desiring to accept them;

(4) A final accounting of the financial affairs of the fund; and

(5) The transfer of the books, records and property of the fund to the custody of the State

Board of Worker’s Compensation.

Upon completion of all matters provided for in such resolutions, but not later than December 31,

2020, the Subsequent Injury Trust Fund and the members of its board of trustees shall be

discharged from their duties except for such personnel necessary to administer any remaining

claims.

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 52

APPENDIX E

GLOSSARY

State of Georgia

Manual for Medical and Physical Examination Program

Revised May 1, 2017 53

GLOSSARY

SI - The American National Standards Institute (ANSI) is a private, non-profit organization (501(c)3) that

administers and coordinates the U.S. voluntary standardization and conformity assessment system

Audiogram - a graphical representation of a person’s auditory sensitivity to sound: a picture of one’s hearing

Audiologist – a person who, by virtue of academic degree, clinical training, and license to practice and/or

professional credential, is uniquely qualified to provide a comprehensive array of professional services related to the

prevention of hearing loss and the audiologic identification, assessment, diagnosis, and treatment of persons with

impairment of auditory and vestibular function, and to the prevention of impairments associated with them

Audiometer – an instrument used to measure the sensitivity of hearing

Decibel (dB) – a logarithmic unit of sound intensity

Hepatitis A – inflammation of the liver caused by a virus that is transmitted by ingestion of infected food and water

Hertz (Hz) – a unit of frequency equal to one cycle per second

Hypertension – persistent high blood pressure

Ocular motility – ability of the eye to move spontaneously

Ophthalmoscopic – examination of the interior structures of the eye

Orthosis (bracing) – an external orthopedic appliance that prevents or assists the movement of the spine or limbs

Otoscopic – examination of the interior of the ear, especially the eardrum

Pathogen – an agent that causes disease

Prosthesis – an artificial device used to replace a missing body part such as a limb

Psychoneurosis – mental or emotional disorder

Salmonella typhi – bacteria that causes typhoid

Shigella – bacteria that causes dysentery

Staphylococcus aureus – bacteria that causes food poisoning

Streptococcus pyogenes – bacteria that causes the formation of pus or fatal septicemias