Protocol packets, forms, and the intervals you're on the hook for
Everything here is meant to save your safety coordinator a phone call. Download what you need, send it to your crew ahead of their appointment, and check your surveillance intervals against the reference below.
Sending an employee in? Point them at the crew instructions →
Built to your protocol, not off a shelf
For programs that follow a defined protocol — baseline and annual HAZWOPER, baseline and annual firefighter, preplacement — we assemble a single packet containing every form that protocol requires, in order, with the exam types and services listed on the cover. Tell us the protocol and we'll send the matching packet.
Baseline Preplacement
Physical, vision, medical and orthopedic history, drug screen, and baseline audiogram.
Baseline & Annual HAZWOPER
Adds the medical surveillance questionnaire, respirator clearance, spirometry, fit test, labs, and audiometry.
Baseline & Annual Firefighter
The HAZWOPER set plus EKG and chest imaging documentation, built for NFPA-style annual evaluations.
Something else
If your program doesn't match one of these, send us the standards you work under and we'll build the packet around them.
Not running a named protocol?
These two cover general occupational health and annual fire department physicals when the exam doesn't map to one of the protocols above.
Occupational Health Exam Packet
Registration and consent, PHI authorization, medical and orthopedic history, physical examination, the OSHA respirator questionnaire, pulmonary function report, audiogram, fit test record, return-to-work release, and the employer authorization.
Download packet (PDF)Annual Firefighter Physical Packet
The same clinical form set configured for fire departments and EMS agencies, with a cover that captures department, rank, station and shift, years of service, and SCBA assignment. Omits the employer authorization page used for contractor billing.
Download packet (PDF) Print versionJust need one form?
Every form below stands on its own — its own letterhead, its own signature block — so you can send a single questionnaire without printing a whole packet. Sending a whole crew in? Start with the Employee Pre-Visit Packet — it bundles every employee-completed form into one file. Individual forms follow, fillable for completing on screen or print for paper.
Provider-completed forms — physical examination, pulmonary function report, fit test record, audiogram, and work status release — are issued from the clinic at the visit and aren't posted here. Need one in advance, a form in Spanish, or a packet built to your program's protocol? Email medcareocc@gmail.com.
The full form set
Every form MedCare uses, in packet order.
| Form | Title | Pages | Completed by |
|---|---|---|---|
MC-100 | Patient Registration & Consent for Evaluation | 1 | Patient |
MC-101 | Consent & Authorization for Disclosure of PHI | 1 | Patient |
MC-102 | Medical History Questionnaire | 1 | Patient |
MC-103 | Orthopedic History Questionnaire | 1 | Patient |
MC-104 | Physical Examination | 1 | Provider |
MC-105 | OSHA Respirator Medical Evaluation Questionnaire | 4 | Employee |
MC-106 | Pulmonary Function Testing Report | 1 | Provider |
MC-108 | Respirator Fit Test Record | 1 | Provider |
MC-109 | Return to Work / School Release | 1 | Provider |
MC-110 | Authorization for Regulatory & Medical Surveillance Exams | 2 | Employer |
MC-111 | Audiometry Questionnaire & Results | 3 | Employee & technician |
MC-112 | Live Audiogram Results | 1 | Technician |
MC-113 | Medical Surveillance Questionnaire | 3 | Employee & provider |
What each program requires, and how often
A working summary for planning your annual schedule. Your own exposure assessment and any client contract requirements govern — check your specific obligations before building a program around this table.
| Program | Standard | Typical testing | Usual interval |
|---|---|---|---|
| Hearing conservation | 29 CFR 1910.95 |
Baseline and annual audiogram, threshold shift review | Baseline at entry, then annually |
| Respiratory protection | 29 CFR 1910.134 |
Medical evaluation questionnaire, provider clearance, fit test | Clearance before first use; fit test at least annually |
| Benzene | 29 CFR 1910.1028 |
Exam plus required blood work | At assignment, then periodically per the standard |
| Respirable crystalline silica | 29 CFR 1910.1053 |
Exam, chest imaging, spirometry, TB evaluation | Initial, then at the standard's recurring interval |
| Lead | 29 CFR 1910.1025 |
Blood lead and ZPP monitoring, medical exam | Frequency driven by blood lead levels |
| Asbestos | 29 CFR 1910.1001 |
Exam, respiratory questionnaire, spirometry | Initial, then annually while exposed |
| Commercial drivers | 49 CFR 391.41–391.43 |
DOT physical and certification | Up to 24 months; shorter when conditions require |
| DOT drug & alcohol | 49 CFR Part 40 |
Pre-employment, random, post-accident, return-to-duty | Per your program and random pool rates |
| Fire service members | NFPA 1582 |
Comprehensive physical, PFT, respirator clearance, labs | Annually |
What to bring to your appointment
Share this with anyone you're sending in. It cuts down on repeat visits.
Photo identification
A government-issued photo ID is required for drug and alcohol testing and for DOT examinations. Bring your CDL if you have one.
Your completed forms
Medical history and the respirator questionnaire, filled out ahead of time. If your employer sent you a packet, bring all of it.
A list of your medications
Names and doses, including anything prescribed recently. If you use corrective lenses or hearing aids, bring them.
Documentation for existing conditions
For a DOT exam, bring letters or forms from your treating providers for any condition that requires them. Missing paperwork is the most common reason a certificate gets delayed.
Before a commercial driver's exam
DOT examinations are governed by federal rule and the forms are federal, not ours. We complete them at the visit — drivers don't need to bring them. What follows is what a driver should have in hand, and where to verify us.
What to bring
Government-issued photo ID and your CDL. A written list of medications with doses and prescribing providers. Glasses, contacts, or hearing aids if you use them. Your last Medical Examiner's Certificate if you have it.
Bring documentation for these
Diabetes treated with insulin, vision or hearing in one ear only, seizure history, heart conditions, sleep apnea, or blood pressure under treatment. A letter or completed form from the treating provider is usually required, and its absence is the most common reason a certificate is delayed or issued short-term.
What you leave with
If you qualify, the Medical Examiner's Certificate is issued at the visit. We complete and retain the Medical Examination Report, and the result is transmitted to the National Registry as required.
Verify your examiner
Only a medical examiner listed on the FMCSA National Registry can perform a DOT physical. Alejandra Flores, APRN, MSN, FNP-BC is listed under National Registry No. 8200872956, certified since May 2022. Look us up before you schedule.
We link to FMCSA rather than hosting copies, so drivers always get the current version. Federal forms are revised periodically and an exam completed on a superseded form can be rejected.
Questions we get from safety coordinators
How fast do we get results back?
Can you test a whole crew at once?
How does billing work?
What results does the employer actually receive?
Do you serve employees who don't speak English?
Do you perform DOT physicals?
Do you take walk-ins?
Do you offer after-hours injury care?
Where are you located and who do you serve?
Can you take over a surveillance program we're already running?
Can't find the form you need?
Call the clinic or send us a note. If it's a form we don't have, we'll build one to your program.