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Firemen and Police Officers Lung Examination Form

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Firefighters and Police Officers Lung Examination Form

PHYSICAL

CHEST X-RAY

STETHOSCOPIC EXAMINATION OF THE LUNGS

SPIROMETER TEST* (OPTIONAL FOR VOLUNTEER FIREFIGHTERS)

*Spirometer testing is to be conducted in accordance with Social Security Regulations entitled "Rules for Determining Disability and Blindness", SSA Publication No.64-014, I.C.N. 436850, June 1985

It is recommended that you contact your personal physician for advice concerning correction of . . .

Please sign one copy of this form and submit it to your employer or organization.

Form OD-2 (rev. 06/14)

Posted 6/27/14

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What the Firemen and Police Officers Lung Examination Form Is

The Firemen and Police Officers Lung Examination Form documents a clinical respiratory assessment used by fire and police departments to screen personnel for occupational lung disease, fitness-for-duty, or eligibility for benefits. It typically records medical history, symptom review, physical exam findings, spirometry or pulmonary function testing results, imaging or radiology notes, and the examining clinician’s opinion. Agencies use the completed form for employment evaluations, program eligibility (presumptive disease lists) and records retention under applicable health privacy and labor rules.

Why this form matters for agencies and clinicians

A clear, standardized lung exam form ensures consistent clinical data collection, supports occupational exposure tracking, and creates an auditable record for benefits, workers’ compensation, or fitness determinations while preserving patient privacy.

Why this form matters for agencies and clinicians

Who completes and relies on this lung examination report

Departments, occupational health clinicians, and insurers each have practical reasons to use the Firemen and Police Officers Lung Examination Form.

  • Occupational health clinicians: document exam findings, test results, and medical opinions for fitness-for-duty decisions.
  • Agency medical officers: review records for assignment, return-to-duty, or exposure tracking.
  • Claims and insurance reviewers: use exam data to evaluate benefits, presumptive disease claims, and compensation eligibility.

Accurate completion reduces follow-up requests and helps preserve eligibility timelines for employment and benefits.

Primary signers and document owners

Examining Clinician

A licensed medical provider (physician, pulmonologist, or qualified occupational medicine clinician) who performs the exam, records findings, signs, and dates the report. Their professional license number and contact information should appear on the form to support verification and credential checks.

Department Official

A designated agency representative (medical director, HR or occupational health manager) who receives and files the completed form, confirms administrative details, and maintains chain-of-custody or claims records for personnel files and benefit decisions.

Essential sections to include in a professional lung exam form

A complete form is structured to capture identifying data, exposure history, objective test results, provider impressions, and administrative metadata to support clinical and administrative decision-making.

Identifying Information

Full name, agency/department, employee ID, date of birth, and current assignment to match the record to personnel files and payroll or benefits systems.

Exposure and Medical History

Work-related exposure summary, smoking history, prior lung disease, medications, and past chest imaging or tests relevant to diagnosis and causation.

Physical Examination

Focused respiratory exam findings including auscultation, oxygen saturation if taken, signs of respiratory distress, and any relevant systemic findings.

Pulmonary Function Tests

Spirometry results with date, pre/post-bronchodilator values, flow-volume loops, and interpretation including percent predicted values and test quality indicators.

Imaging and Labs

Chest X-ray or CT summary, radiologist report date, and relevant laboratory values supporting clinical assessment.

Provider Opinion

Clear medical opinion on fitness-for-duty, work restrictions, follow-up plan, and signature with clinician name, license and date.

Required data elements and administrative metadata

Full Legal Name: As on government ID
Agency/Unit: Department and unit
Date of Birth: MM/DD/YYYY
Exam Date: MM/DD/YYYY
Clinician Signature: Signed and dated
Test Documentation: Attached reports

Step-by-step: completing the lung exam form

Follow these operational steps to collect accurate clinical data and produce an auditable record for the agency and claimant.

  • 01
    Prepare records: Gather prior imaging, test reports, and exposure history before the exam.
  • 02
    Conduct exam: Perform focused respiratory exam and obtain spirometry per ATS standards.
  • 03
    Record findings: Enter objective values, attach reports, and note test quality.
  • 04
    Sign and route: Clinician signs, date-stamps, and forwards to occupational health file.

Typical submission and review workflow

A straightforward routing model helps agencies manage intake, clinical review, and administrative storage while preserving the audit trail.

  • Intake: Employee or clinic uploads completed form to agency portal or secure email.
  • Clinical review: Occupational health reviews test quality and clinical opinion.
  • Administrative filing: Record indexed into personnel and medical files with access controls.
  • Claims support: Copy provided to claims or legal teams as needed for benefits determinations.

Configuring an online form workflow for lung examinations

Design the online workflow to collect required fields, enforce required attachments, and route signed copies to the right recipients.

Field Configuration
Required fields Make name, DOB, exam date mandatory
Attachments Require spirometry PDF and radiology reports
Routing Auto-send to agency medical reviewer
Retention Set archival period per policy

Digital signing and system requirements

Use a secure platform that supports audit trails, access controls, and HIPAA-level protections when handling protected health information.

  • Document formats: PDF or DOCX accepted
  • Authentication: Email plus optional MFA
  • Integrations: Connectors for HR and EHR

Ensure the chosen system can produce a tamper-evident signed copy, maintain an audit trail, and support a business associate agreement when HIPAA applies.

eSignature vendor comparison for signing and routing lung exam forms

Basic plan pricing, core features, and HIPAA support vary. signNow is listed first to simplify procurement comparisons; verify each vendor’s current plan details before purchasing.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Free trial available Free trial available Free trial available Free trial available
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Practical tips for accurate, auditable completion

Use consistent formats, require attachments, and preserve an audit trail to reduce rework and disputes.

Use standard date and name formats
Enter dates in MM/DD/YYYY and the employee’s full legal name exactly as on government ID to prevent record mismatches and processing delays.
Attach original test reports
Include raw spirometry printouts, radiology reports, and lab results to support numeric values and clinical interpretations recorded on the form.
Enforce required fields
Make clinician signature, license number, and test quality indicators mandatory to avoid incomplete records that can invalidate claims.
Preserve electronic audit trails
Use platforms that capture timestamps, IP addresses, and change history to support authentication and chain-of-custody during reviews or appeals.

Common mistakes to avoid when preparing this form

  • Incomplete test attachments that prevent independent review of spirometry quality and validity.
  • Mismatched names or IDs between form and personnel files causing administrative rejects.
  • Missing clinician license number or sign-off reducing evidentiary weight for claims.
  • Using ambiguous language for work restrictions instead of specific, time‑bound limitations.

Consequences of incorrect, missing, or mishandled lung exam records

Claims denial: Incomplete evidence
Legal exposure: Poor documentation
Privacy violation: HIPAA breach risk
Delays: Processing setbacks
Financial loss: Higher defense costs
Reputational harm: Agency trust erosion

Typical timelines and processing expectations

Timely completion and routing minimize administrative delays and preserve eligibility windows for benefits and duty assignments.

Exam Completion:

Complete and sign on the date of service

Agency Filing:

Submit to occupational health within 7 days

Claims Submission:

Provide documents to insurer within claim deadline

Retention Start:

Retention begins on the exam date

Audit Availability:

Make records available on request within 30 days

How to download, save, and export completed forms

Maintain signed copies in PDF/A for long-term archival and keep editable copies for administrative updates; include audit metadata when exporting.

PDF/A Export

Save the final signed record as a PDF/A file to preserve layout and support long-term archiving. Include the audit trail as an embedded attachment or separate PDF.

XML or CSV Data

Export structured field data as XML or CSV for integration with HR, claims, or EHR systems to enable analytics and bulk processing while keeping the signed PDF as the legal record.

Secure Storage

Store files in encrypted repositories with role-based access controls, audit logging, and regular backups to maintain integrity and meet retention obligations.

Versioning

Use version control for form revisions and retain prior signed versions to preserve a clear history of medical opinions and changes.

Real-world examples of form use

These brief case arcs illustrate how the form supports agency decisions, claims review, and clinical follow-up.

Agency Fitness Review

A city fire department required baseline spirometry for new hires to establish pre-exposure data

  • The clinician recorded pre/post values and signed the form
  • The agency retained the signed PDF and used the measurements to compare future testing and adjudicate a later presumptive claim.

Claims Adjudication

An officer filed a presumptive lung disease claim after long-term exposure

  • The insurer requested the completed lung exam form and attachments
  • Clear spirometry, radiology reports, and a dated clinician opinion supported benefits approval and reduced dispute time.

Frequently asked questions about the lung examination form

Answers below cover signature validity, HIPAA concerns, attachments, and common processing questions for clinicians and agencies.


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