SECTION 3 MTF Monitor/CMA: Authorized MTF records reviewer/CMA answer all questions based on the review of all known health records. Explain any NO answers in Section 5. Is there any medical evidence of any of the following? 1 Alcohol-related incidents, abuse or dependence? Yes No 2 Illicit drug-related incidents or use? Yes No 3 Abuse of substances that alter perception or mental faculties such as sniffing or Yes No huffing etc? 4 Any aberrant mood swings, irrational behavior or other mental health issue of Yes No concern? 5 Suicidal ideation or attempts? Yes No 6 Physical condition that would impair or distract ability to perform PRP duty? Yes No 7 Condition that could impair the alertness or reliability of the member? Yes No 8 Family advocacy concern or evidence of poor social adjustment? Yes No 9 Abuse of any prescription, over-the-counter medication or herbal supplement? Yes No 10 Any trauma or condition that might affect reliability such as severe headaches, Yes No history of severe head trauma, loss of consciousness, stroke, etc? 11 Current requirement or use any prescription medication, over-the-counter Yes No medication, herbal supplement or dietary aid that might decrease alertness or cause impairment? 12 Any other medical concern that should be considered potentially disqualifying Yes No information (PDI)? Any question answered yes requires a PDI letter. A PDI letter (is / is not) required and therefore a copy (has / has not) been filed in the medical record. member’s Member (was / was not) interviewed. I have completed my medical assessment and recommend that member (be/ not be) certified. (MEDICAL (DATE) REVIEWER SIGNATURE) NOTE: If this form contains PDI or if this is a screening for an administrative qualification, it must be signed by the CMA or IDMT at GSU.
SECTION 3 MTF Monitor/CMA: Authorized MTF records reviewer/CMA answer all questions based on the review of all known health records. Explain any NO answers in Section 5. Is there any medical evidence of any of the following? 1 Alcohol-related incidents, abuse or dependence? Yes No 2 Illicit drug-related incidents or use? Yes No 3 Abuse of substances that alter perception or mental faculties such as sniffing or huffing etc? Yes No 4 Any aberrant mood swings, irrational behavior or other mental health issue of concern? Yes No 5 Suicidal ideation or attempts? Yes No 6 Physical condition that would impair or distract ability to perform PRP duty? Yes No 7 Condition that could impair the alertness or reliability of the member? Yes No 8 Family advocacy concern or evidence of poor social adjustment? Yes No 9 Abuse of any prescription, over-the-counter medication or herbal supplement? Yes No 10 Any trauma or condition that might affect reliability such as severe headaches, history of severe head trauma, loss of consciousness, stroke, etc? Yes No 11 Current requirement or use any prescription medication, over-the-counter medication, herbal supplement or dietary aid that might decrease alertness or cause impairment? Yes No 12 Any other medical concern that should be considered potentially disqualifying information (PDI)? Yes No Any question answered yes requires a PDI letter. A PDI letter (is / is not) required and therefore a copy (has / has not) been filed in the member’s medical record. Member (was / was not) interviewed. I have completed my medical assessment and recommend that member (be/ not be) certified. (MEDICAL REVIEWER SIGNATURE) (DATE) NOTE: If this form contains PDI or if this is a screening for an administrative qualification, it must be signed by the CMA or IDMT at GSU.
PRPQuestionnaire.docx