Worksafe Bc Form 55M5 PDF Details

The WorkSafe BC 55M5 form plays a critical role in ensuring the safety and effectiveness of occupational first aid attendants within the workplace. Designed as a comprehensive assessment tool, this form is meticulously detailed to evaluate a candidate's medical and psychological fitness for performing first aid duties. Through a series of structured questions, examining physicians are guided to scrutinize various aspects of a candidate's health, including disease conditions, visual and hearing acuity, fine motor skills, physical fitness, lifting ability, and even potential medication that could impair performance. This form also delves into past issues related to substance abuse and psychological or emotional illnesses, which could impact the candidate's ability to handle high-stress situations. Required to be completed by a physician, the form captures not only the candidates' medical history but also assesses their current state through the physician's professional opinion. In essence, the WorkSafe BC 55M5 form serves as a safeguard, ensuring that only those truly capable are certified to administer first aid, thus maintaining a safe and responsive work environment.

QuestionAnswer
Form NameWorksafe Bc Form 55M5
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameselevations, certificationworksafebc, immobilize, pallor

Form Preview Example

 

OCCUPATIONAL FIRST AID

 

MEDICAL CERTIFICATE OF FITNESS

 

Report of Examining Physician

CERTIFICATION SERVICES

EMAIL

Phone 604 276-3090

certification@worksafebc.com

Toll-free 1 888 621-7233, ext. 3090

 

Examining physician, please note:

1.The fee for the services of the physician is the responsibility of the candidate.

2.It is essential that the candidate be PHYSICALLY and PSYCHOLOGICALLY fit to perform the duties of an occupational first aid attendant.

Please print

Surname of candidate

 

Given name(s) in full

 

Mr.

Ms.

 

 

 

 

 

Mrs.

Miss

 

 

 

 

 

 

Mailing address

 

 

 

Date of birth (yyyy-mm-dd)

 

 

 

 

 

 

City

 

 

 

Province

Postal code

 

 

 

 

 

 

 

 

1. Disease conditions — Is there MEDICAL EVIDENCE and/or a HISTORY of

 

 

 

Seizure disorder

Yes

No

Respiratory disease

Yes

 

No

Hernia

Yes

No

Heart disease

Yes

 

No

Communicable disease

Yes

No

Multiple sclerosis

Yes

 

No

Diabetes

Yes

No

Other (not otherwise specified)

Yes

 

No

If yes, please explain if this disease could affect the candidate’s ability to perform the duties of an

 

 

 

occupational first aid attendant

 

 

 

 

 

 

 

 

 

2. Alcohol or substance abuse — Has the candidate experienced any problems in the PREVIOUS12 MONTHS,

 

 

relative to the overuse and/or addiction to ALCOHOL, RECREATIONAL or PRESCRIPTION DRUGS,

 

 

 

and/or OVER-THE-COUNTER MEDICATION?

 

 

Yes

 

No

If yes, please explain

 

 

 

 

 

 

 

 

 

3. Psychological and/or emotional illness — At the work site, first aid attendants may be involved in stressful,

 

 

emotional, and/or tense situations. Has the candidate exhibited and/or experienced any PSYCHOLOGICAL

 

 

OR EMOTIONAL episode which could preclude the candidate from performing the duties of an

 

 

 

occupational first aid attendant?

 

 

 

Yes

 

No

If yes, please explain

 

 

 

 

 

 

 

 

 

4. Visual acuity — Would the candidate (with appropriate visual correction, if required) be able to observe an

 

 

accident scene from a distance, assess minor wounds, remove small slivers, remove small particles from

 

 

the eye, and/or assess a patient for pallor and contusions?

 

Yes

 

No

If no, please explain

 

 

 

 

 

 

 

 

 

5. Hearing acuity — Would the candidate (with appropriate hearing correction, if required) be able to hear a

 

 

summons for first aid, hear and assess breathing on a patient who may not be visible to him/her (i.e., is out

 

 

of sight), distinguish if there is distressed breathing, and/or verbally communicate with a patient?

Yes

 

No

If no, please explain

 

 

 

 

 

 

 

 

 

55M5

Workers’ Compensation Board of B.C.

(R08/12) Page 1 of 2

Occupational First Aid Medical Certificate of Fitness (continued)

Surname of candidate

Given name(s)

6. Fine motor skills — upper limbs— Does the candidate have a MOTOR OR SENSORY impairment of

 

one or both of the upper extremities which could impair his/her ability to assess a pulse, palpate for point

 

tenderness, remove particles from the eye, immobilize a limb, assess and treat open wounds?

Yes

If yes, please explain

 

No

7. Physical fitness — First aid attendants may have to traverse rough terrain such as steep banks, climb over

 

fallen trees or logs, access areas such as excavations or high elevations. Does the candidate have a

 

physical condition which could limit his/her ability to render first aid under these conditions?

Yes

If yes, please explain

 

No

8. Lifting ability — First aid attendants may have to assist in transporting a patient, secured to a lifting device,

 

over rough terrain. They may also have to carry equipment weighing up to 50 lb. (22.680 kg). Does the

 

candidate have a physical condition which could limit his/her ability to render first aid under these conditions?

Yes

If yes, please explain

 

No

9. Medication — Is the candidate taking any medication which could affect his/her ability to render first aid?

Yes

If yes, please explain

No

10. Professional opinion — In summary, in your professional opinion, do you have confidence in this candidate’s

 

PHYSICAL and/or PSYCHOLOGICAL FITNESS to render emergency pre-hospital care to workers?

Yes

If no, please explain

 

No

Physician’s name (please print)

Physician’s signature

Phone number (include area code)

Street address

City

Province

Postal code

Date (yyyy-mm-dd)

Clinic or physician’s stamp

Candidate’s statement

 

 

I have answered all questions from my physician, Dr.

 

 

, honestly and truthfully, and I was

forthcoming with Dr.

 

regarding any physical or mental condition that would have a

bearing upon my PHYSICAL or MENTAL ASSESSMENT.

 

 

Candidate’s signature

Date (yyyy-mm-dd)

55M5

(R08/12) Page 2 of 2

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