A Tennessee Paramedic Can Serve as the PLHCP for OSHA Respirator Medical Evaluation Questionnaire

Occupational Safety and Health Administration (OSHA) regulation 29 CFR 1910.134 requires that employers involved in working in atmospheres that expose workers to respiratory hazards have a written respiratory protection program. The employer shall provide respirators, training, and medical evaluations at no cost to the employee (29 CFR 1910.134(c)(4)). Before any employee may use any form of respiratory protection, the employee must have a medical evaluation. Appendix C to Section 1910.134 contains the OSHA Respirator Medical Evaluation Questionnaire. This questionnaire is mandatory for any employee who may be exposed to a respiratory hazard and who may be required to use any form of respiratory protection. The requirements for administration of the medical evaluations and the proper use and dissemination of the information obtained from the evaluations and questionnaires is as follows:

• The employer must identify a physician or other licensed health care professional (PLHCP) to perform all medical evaluations using the OSHA Respirator Medical Evaluation Questionnaire (Mandatory), or a medical examination that obtains the same information (29 CFR 1910.134(e)(2)(i)).
• The medical evaluation must obtain the information requested in Sections 1 and 2, Part A of Appendix C. The questions in Part B of Appendix C may be added at the discretion of the health care professional (29 CFR 1910.134(e)(2)(ii)).
• The employer must ensure that a follow-up medical examination is provided for any employee who gives a positive response to any question among questions 1 through 8 in Part A Section 2, of Appendix C, or whose initial medical examination demonstrates the need for a follow-up medical examination. The employer must provide the employee with an opportunity to discuss the questionnaire and examination results with the PLHCP (29 CFR 1910.134(e)(3)(i)).
• The medical questionnaire and examinations must be administered confidentially during the employee’s normal working hours or at a time and place convenient to the employee and in a manner that ensures that he or she understands its content. The employer must not review the employee’s responses, and the questionnaire must be provided directly to the PLHCP (29 CFR 1910.134(e)(4)(i)).
• The PLHCP must provide a written copy of the recommendation to the employee and the employer.

Tennessee Paramedics Can Serve as the PLHCP

The OSHA regulation defines a physician or other licensed health care professional (PLHCP) as “an individual whose legally permitted scope of practice (i.e., license, registration, or certification) allows him or her to independently provide, or be delegated the responsibility to provide, some or all of the health care services required by paragraph (e) of this section” (29 CFR 1910.134(b)).

The employer must provide the PLHCP with a copy of the written respiratory protection program and a copy of the section 1910.134 (29 CFR 1910.134(e)(5)(iii)).

OSHA Respiratory Protection Standard 1910.134 requires that any person who will use a respirator undergo a medical evaluation before they are fit tested and allowed to use a respirator. The medical evaluation consists of two parts. The first part is a written medical questionnaire that must be performed (i.e. administered and evaluated) by a physician or other licensed health care provider (PLHCP). The employer gives the employee a copy of the questionnaire to complete. The employee completes the questionnaire and sends or takes it to a PLHCP for evaluation. The PLHCP evaluates the questionnaire and determines if the person is fit to wear and use a respirator. If certain questions are answered “yes,” (these are questions 1 through 8 in Part A, Section 2) the PLHCP evaluating the questionnaire refers the candidate to someone who can conduct a physical examination.

In November 2016, Dr. Joe Holley, Medical Director for the State of Tennessee, ruled that the scope of practice of a Tennessee licensed paramedic allows the paramedic to evaluate the first part (questions 1 through 8 in Part A, Section 2) of the medical questionnaire. If the paramedic evaluating the medical questionnaire determines that the candidate is not qualified (a positive answer to any of the eight questions in this section), or if the paramedic is not sure if the candidate is qualified, then the paramedic, as the initial PLHCP, must refer the candidate to another PLHCP who is qualified to perform a physical examination.

As a result of Dr. Holley’s determination, a city, town, or fire department can use a paramedic for the initial screening, which may be more cost effective that using a physician or other licensed health care professional. The paramedic may not share the actual answers to the questionnaire with the employer, but must provide the employer with the following information:

1. any limitations on respirator use related to the medical condition of the employee, or relating to the workplace conditions in which the respirator will be used, including whether or not the employee is medically able to use the respirator;
2. the need, if any, for the employee to have follow-up medical evaluations; and
3. a statement that the PLHCP has provided the employee with a copy of the PLHCP's written recommendation.

If the initial evaluation indicates the need for further screening, the employer shall ensure that a follow-up medical examination is provided for an employee who gives a positive response to any question among questions 1 through 8 in Section 2, Part A of Appendix C, or whose initial medical examination demonstrates the need for a follow-up medical examination (29 CFR 1910.134(e)(3)(i)). The follow-up medical examination must include any medical tests, consultations, or diagnostic procedures that the PLHCP deems necessary to make a final determination (29 CFR 1910.134(e)(3)(ii)).

The actual questionnaires and exam results should not be shared with the employer or the public, so the paramedic acting as the PLHCP should maintain the records in order to ensure the confidentiality required by 29 CFR 1910.134(e)(4)(i).

The employer should maintain the recommendation that the PLHCP sends to the employer following the evaluation of the medical questionnaire.