Page 31 - DIDC SOPS and Guidelinesv as of April 2019

DIDC-A Medical & Dental Checklist PMO-6018-01-f
Internal Use Only
Contingency Released Date
Operations 03/06/17 Page 1 of 1

CANDIDATE NAME: _____________________________________
SSN#: ____________________________ Job Title: ____________________________________

Initials Date
Physical
Physical Exam (within1yr) ____________ ______________
Body Mass Index Results ____________ ______________
Optic (Snelling Wall Chart) ____________ ______________
Audiogram ____________ ______________
EKG (over 40 attach the original Tracing) ____________ ______________
Framingham (over 40) ____________ ______________
Pulmonary Function Test (FF, Vector, currently treated for asthma) ____________ ______________

Lab Result
Blood Type ____________ ______________
HIV ____________ ______________
G6PD ____________ ______________
Urinalysis ____________ ______________
CBC ____________ ______________
Lipid Panel (over 35) ____________ ______________
Fasting Glucose ____________ ______________
HgbA1C (Diabetic, FBG >125) ____________ ______________
Pregnancy test (within 30 days) ____________ ______________
Hep C (Kuwait only) ____________ ______________
RPR (Kuwait only) ____________ ______________
Hep B (Kuwait only) ____________ ______________
Food Service labs (if applicable) ____________ ______________
Cholinesterase (Vector Control only) ____________ ______________
DNA (if not on Record) ____________ ______________
Quantiferon Test/ TB skin test ____________ ______________

Shots
Hep A ____________ ______________
Hep B ____________ ______________
MMR ____________ ______________
Tetanus/Diphtheria/Pertussis ____________ ______________
Typhoid ____________ ______________
Influenza ____________ ______________
Varicella (1 dose) ____________ ______________
st
Varicella (2 dose) ____________ ______________
nd
Polio (AFG Only) ____________ ______________
Rabies (Vector Control and dog handlers) ____________ ______________
Yellow fever/Meningococcal (Africa /Djibouti) ____________ ______________

Dental
Form DD 2813 (completed by your Dentist) ____________ ______________
360 Panarex (within 1 year) ____________ ______________

Medication
180 days of any prescribed medication prior to arrival to the DIDC ____________ ______________
Malaria Pills 1 yr. prescription (Afghanistan & India AOR) ____________ ______________

Validated by: ___________________________ Date: _________________________

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No part of it may be used, circulated, quoted, or reproduced for distribution outside of DI without the prior written approval of DI.