Pre-Placement/Post Offer Medical Examinations
Table of Pre-Employment/Post–Offer Contracted Clinics and County Classifications
Pre-Employment/Post-Offer Questionnaires
- Dispatcher Medical History Statement
- Firefighter Health History Questionnaire
- Peace Officer Medical History Statement
- Pre-Employment Health History Questionnaire
- Respirator Medical Evaluation Questionnaire
Pre-Employment/Post-Offer Examinations Data Forms
Miscellaneous Forms & Links
- Body Composition Standards
- Body Fat Letter
- Body Fat Worksheet
- DMV Form MCSA-5875
- DMV Form MCSA-5876
- HRR Color Instructions and Form
- Drug Test Notification Form
- Exercise Challenge Test Form
- Titmus Results Form with Signal Lights
- IMO Final Findings Report
- Employee Medical Evaluation Clearance Form for Respirator Use
- Supplemental Notice to Department OHP
Periodic & Mobile Examinations
Protocol Sheets
- Armed Reserve Pool
- Asbestos
- Clandestine Lab
- Commercial Drivers
- Confined Space
- Crane Operator
- FBI Bomb School
- HAZMAT
- Hearing Conservation
- Hearing & Lead
- Hearing & Respirator
- ILL-at-Work
- Lead
- Respirator
- Retirement Exemption Exam (Fire Department)
- Return-to-Work
- SCUBA
- TB Screening
Questionnaires
- Armed Reserve Pool
- Asbestos, Initial
- Asbestos, Annual
- Clandestine Lab
- Commercial Drivers Supplemental
- Confined Space
- Crane Operator
- FBI Bomb School/FD-1065
- HAZMAT
- Hearing Conservation
- Respirator
- Retirement Exemption (Fire Department)
- SCUBA
Periodic Examination Data Forms
Miscellaneous Forms & Links
- DMV Form MCSA-5875
- DMV Form MCSA-5876
- Employee Medical Results Form
- Hazardous Devices School Physical Capacities Form
- Hepatitis B Declination Form
- Medical Examiner’s Note
- Titmus Results Form with Signal Lights
Wellness Service Grouping
Protocol Sheets
- Fitness-for-Life (Age= Age 2 months from today) — New
- Commercial Driver’s Medial Evaluation (Completed on day of Fitness-for-Life) — New
- Executive (Please call Nina Arbet-Brandt at (213) 738-2177 for a customized Executive Protocol Sheet.)
- HAZMAT (Completed on day of Fitness-for-Life) — New
- Optional Blood Panel Testing — New
- SCUBA (Completed on day of Fitness-for-Life) — New
Questionnaires
- Drivers Supplemental — New
- Executive
- Family History — New
- Fitness-for-Life — New
- HAZMAT
- SCUBA
Consent Forms
- Consent for Fitness-for-Life Medical Exam, Auditing & Record Release — New
- Consent For Optional Blood Testing — New
- Consent for Physical Fitness Assessment, Auditing & Record Release — New
Miscellaneous Forms and Worksheets
- FFL Body Fat Worksheet — New
- Cardiovascular Fitness Worksheet
- Coronary Calcium Scan Request (Harbor-UCLA) — New
- Coronary Calcium Scan Request (SCV/Irwindale Sub-contractor) — New
- DMV Form MCSA-5875
- DMV Form MCSA-5876
- Employee Medical Results Form
- FFL Medical Exam Compliance Form (Fire Dept) — New
- FFL Medical Exam Compliance Form (Parks & Rec Dept) — New
- Gerkin Protocol Worksheet
- Medical Examiner’s Note — New
- Strength and Flexibility Worksheet
- Titmus Results Form with Signal Lights
- Treadmill Reading Request (Harbor-UCLA) — New
- Wellness Examination Data Form — New
