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Home My WebLink About106.141 - FD-79, Medical Status Report Form ADMINISTRATIVE MANUAL FORMS 106.141 MEDICAL STATUS REPORT FORM (FD-79) EFFECTIVE: MAY 2011 Current Revision Date: 04/26/21 Next Revision Date: 04/26/24 Author’s Name/Rank: Bradley Dandridge, Battalion Chief Review Level: 1 Administrative Support: Evelyn Yin-Zepeda, Management Analyst II PURPOSE This policy ensures proper documentation of all injuries sustained during the course of employment with the City of Fresno (City) Fire Department (FFD or Department). APPLICATION This form is utilized by member’s attending physician to document the member’s work status capabilities i.e., modified (light) duty, full-duty capacity, or no work assignment allowed. OPERATIONAL POLICY This section intentionally left blank. OPERATIONAL GUIDELINE The Medical Status Report form is to be completed whenever a member seeks medical treatment or hospitalization and submitted to the Safety and Wellness Officer within one business day of physician’s visit. PROCESS There are three versions of the (FD-79A through FD-79D), listing specific physical requirements for the following work categories: Sworn Safety Members (FD-79A). Sworn Non-Safety Members (FD-79B). Support Personnel (FD-79C). The FD-79 forms are used by the member’s attending physician to document the member’s ability or inability to return to work from an injury or illness. The form can be hand delivered to the physician by the member or sent via fax or email to the Safety and Wellness Officer at headquarters. The attending physician is to use the form to indicate the member’s available work status, including any physical restrictions the member may have. The FD-79 forms divide possible duty assignments into three categories: Modified (light) duty. Full duty. No work assignment allowed. The forms include a detailed list of modified (light) and full duty work assignment requirements. Completing the Forms The attending physician is to review and complete the appropriate FD-79 form in its entirety. The physician should include a “date of maximum medical improvement” (projected return to work date). The physician must sign the form and check the box, which indicates he/she has read and understands the modified (light) and full duty work assignment requirements listed on the form. Once completed, the member may hand deliver the form to Headquarters or scan and email or fax to the Safety and Wellness Officer. Note: If the form is to be emailed or faxed to headquarters, the physician’s staff must call the Safety and Wellness Officer and advise him/her the form will be sent in this manner. Failure to submit the form may result in disciplinary action. Section 106.141 Page 2 of 6 DEFINITIONS This section intentionally left blank. CROSS-REFERENCES Administrative Order No. 2-23, Reasonable Accommodations for Employees with Medical Disabilities or Conditions Administrative Manual Section 110.001, Guidelines and Responsibilities Section 110.004, Modified (Light) Duty Section 110.005, Physical Minimum Qualifications (PMQ) Section 106.141 Page 3 of 6 □ □ □ □ □ □ FD-79A MEDICAL STATUS REPORT FORM SWORN SAFETY MEMBERS PATIENT’S NAME: DATE: INJURY/ILLNESS DATE: INJURY/ILLNESS DESCRIPTION: DATE OF MAXIMUM MEDICAL IMPROVEMENT: DATE OF NEXT APPOINTMENT: While the employee continues to receive medical care, he/she may perform the following type of work: Modified (Light) Duty Work: Full Duty work No Work Allowed Yes Yes No No Other limitations or restrictions: PHYSICIAN’S NAME: PHYSICIAN’S SIGNATURE: DATE: ADDRESS: PHONE NO. MODIFIED AND FULL DUTY WORK ASSIGNMENT REQUIREMENTS FOR SWORN SAFETY MEMBERS MODIFIED (LIGHT) DUTY (Monday-Friday, 0800-1700 Hours Shift Schedule) Clerical Work: Answering phones, monitoring surveillance videos. Light Office Work: All of the above plus filing, using office machines (i.e., copiers and printers), sorting and delivering inter-office mail, answering questions at front desk while sitting or standing, using computer for data entry. Moderate Work: All of above plus driving, lifting boxes/equipment with or without weight limit, delivering supplies to fire stations, sorting supplies and equipment with or without weight limit. FULL DUTY WORK PHYSICAL MINIMUM QUALIFICATIONS (PMQ) [24-Hour Shift Schedule] All of the above plus may be exposed to extremes in temperatures, from the heat of building fires to cold water rescues and work in wet and dirty conditions regularly. At times will be asked to carry heavy equipment (50 to 100 pounds) in multiple positions and on uneven ground. Can be required to manipulate large hand tools in multiple positions and forcefully use striking tools. Work pace during a shift can be extremely erratic and unpredictable. At times can be required to walk, run, and/or crawl on hands and knees. Will be required to wear safety gear including coats, pants, gloves, and helmets and work with gear on, in multiple environments and conditions; gear may weigh up to 45 pounds. Will require full range of motion with safety gear on and exceptions to safety gear usage and/or fit is rarely acceptable. Will be required to wear a self-contained breathing apparatus, which weighs up to 30 pounds and requires a tight seal around the face for operation. During emergency operations can be required to perform CPR, lift and/or carry patients in tight spaces and possibly up and down stairs and/or on steep grades. At times will be required to climb multiple types of ladders up to 100 feet tall, possibly carrying equipment and/or people. Maintaining mental capacity, allowing for effective interaction and communication with others. I have read and understand the above modified and full duty work assignment requirements. Note: Please contact the Safety and Wellness Officer at the Fresno Fire Department at 621-4177 for any comments or clarifications. Section 106.141 Page 4 of 6 □ □ □ □ □ □ FD-79B MEDICAL STATUS REPORT FORM SWORN NON-SAFETY MEMBERS PATIENT’S NAME: DATE: INJURY/ILLNESS DATE: INJURY/ILLNESS DESCRIPTION: DATE OF MAXIMUM MEDICAL IMPROVEMENT: DATE OF NEXT APPOINTMENT: While the employee continues to receive medical care, he/she may perform the following type of work: Modified (Light) Duty Work: Full Duty work No Work Allowed Yes Yes No No Other limitations or restrictions: PHYSICIAN’S NAME: PHYSICIAN’S SIGNATURE: DATE: ADDRESS: PHONE NO. MODIFIED AND FULL DUTY WORK ASSIGNMENT REQUIREMENTS FOR SWORN NON-SAFETY MEMBERS MODIFIED (LIGHT) DUTY Clerical Work: Answering phones, monitoring surveillance videos. Light Office Work: All of the above plus filing, using office machines (i.e., copiers and printers), sorting and delivering inter-office mail, answering questions at front desk while sitting or standing, using computer for data entry. Moderate Work: All of above plus driving, lifting boxes/equipment with or without weight limit, delivering supplies to fire stations, sorting supplies and equipment with or without weight limit. FULL DUTY WORK PHYSICAL MINIMUM QUALIFICATIONS (PMQ) Maintaining physical condition appropriate to the performance of assigned duties and responsibilities which may include walking, standing, or sitting for extended periods of time. Lifting and operating assigned equipment. Walking on uneven and/or slippery surfaces. Reaching for items above the head and below the feet. Operating fire hydrants. Climbing up and down ladders. Entering confined environments. Moving quickly and easily, crawling, stooping, or bending. Visual acuity sufficient to read gauges and observe conditions at inspection sites in a variety of lighting conditions. Maintaining effective audio-visual discrimination and perception needed for making observations, communicating with others, reading and writing, and operating assigned equipment. Maintaining mental capacity, allowing for effective interaction and communication with others. I have read and understand the above modified and full duty work assignment requirements. Note: Please contact the Safety and Wellness Officer at the Fresno Fire Department at 621-4177 for any comments or clarifications. Section 106.141 Page 5 of 6 □ □ □ □ □ □ FD-79C MEDICAL STATUS REPORT FORM SUPPORT STAFF PATIENT’S NAME: DATE: INJURY/ILLNESS DATE: INJURY/ILLNESS DESCRIPTION: DATE OF MAXIMUM MEDICAL IMPROVEMENT: DATE OF NEXT APPOINTMENT: While the employee continues to receive medical care, he/she may perform the following type of work: Modified (Light) Duty Work: Full Duty work No Work Allowed Yes Yes No No Other limitations or restrictions: PHYSICIAN’S NAME: PHYSICIAN’S SIGNATURE: DATE: ADDRESS: PHONE NO. MODIFIED AND FULL DUTY WORK ASSIGNMENT REQUIREMENTS FOR SUPPORT STAFF MODIFIED (LIGHT) DUTY Clerical Work: Answering phones, monitoring surveillance videos. Light Office Work: All of the above plus filing, using office machines (i.e., copiers and printers), sorting and delivering inter-office mail, answering questions at front desk while sitting or standing, using computer for data entry. Moderate Work: All of above plus driving, lifting boxes/equipment with or without weight limit, delivering supplies to fire stations, sorting supplies and equipment with or without weight limit. FULL DUTY WORK PHYSICAL MINIMUM QUALIFICATIONS (PMQ) Maintaining physical condition appropriate to the performance of assigned duties and responsibilities, which may include walking, standing, bending, squatting, turning, twisting, climbing steps, or sitting several times a day or for extended periods of time. Lifting and operating assigned equipment (under 25 lbs.). Reaching for items above the head and below the feet. Maintaining effective audio-visual discrimination and perception needed for making observations, communicating with others, reading and writing, and operating assigned equipment. Maintaining mental capacity, allowing for effective interaction and communication with others. I have read and understand the above modified and full duty work assignment requirements. Note: Please contact the Safety and Wellness Officer at the Fresno Fire Department at 621-4177 for any comments or clarifications. Section 106.141 Page 6 of 6