Emergency response is a physically demanding occupation; approximately half of all firefighter on-duty and line-of-duty deaths are due to cardiovascular events. Emergency response activities can place a tremendous strain on the cardiovascular system, which can trigger a catastrophic cardiovascular event. This is especially true for team members and responders with pre-existing heart conditions, which they may or may not be aware of. Emergency response activities often involve activities that increase the risk of team member and responder musculoskeletal injuries, e.g., lifting and carrying heavy loads (equipment, PPE, victims, etc) in awkward positions, sustained use of equipment that may result in injuries related to repetitive motion, ergonomically unsafe cutting angles when safer approaches are unavailable, or vibration.
Emergency response activities often occur in extreme environmental conditions that increase risks for heat or cold injury. Noise from sirens, alarms, and equipment motors can induce hearing loss, especially if the noise exposure is occurring in situations where it may be concurrent with exposure to carbon monoxide or other substances known to have synergistic effects with noise on hearing loss, especially as many responders may not use hearing protection devices out of concern for effective communication with others on the scene.
Emergency response activities may also involve exposure to numerous toxic substances. Team members and responders may be exposed to combustion products produced by the fire they are responding to as well as from the operation of their equipment/apparatus, hazardous materials when material releases occur, and infectious diseases during emergency medical responses that may result in adverse health effects to team members and responders. Additionally, exposure to combustion products increases team members’ and responders’ risk of developing several different kinds of cancer.
Finally, emergency response activities expose team members and responders to traumatic, emotionally charged events, and the impact of these events on responders’ mental health is compounded by inadequate duration and quality of sleep due to the unpredictable nature of calls, which is exacerbated by frequently working back-to-back long shifts and excessive overtime, especially in understaffed fire departments. Mental health issues may be worsened by perceived stigma regarding use of mental health services.
Proposed paragraph (g) includes medical and physical requirements to address these hazards. The physical fitness and physical and mental medical requirements in paragraph (g) serve two purposes:
- ensuring that responders are physically and mentally capable of performing their duties without injury to themselves or their fellow responders and
- identifying and addressing physical and mental health effects resulting from emergency response activities
Most major emergency response organizations support medical evaluation of emergency responders. The International Association of Fire Fighters (IAFF) and International Association of Fire Chiefs (IAFC) include medical evaluation consistent with NFPA 1582 in their Joint Labor-Management Wellness-Fitness Initiative. The National Volunteer Fire Council (NVFC) recommends getting an annual physical in their Lavender Ribbon Report – Best Practices for Preventing Firefighter Cancer. The National Fallen Firefighter Foundation (NFFF) recommends medical physicals in their 16 Firefighter Life Safety Initiatives.
Comprehensive medical evaluations are also recommended by NFPA in NFPA 600 and NFPA 1582.
OSHA agrees with the industry consensus that medical evaluation and surveillance is necessary for team members and responders who perform emergency response duties. The agency has preliminarily determined that the medical and physical requirements in proposed paragraph (g) are essential elements of a standard for emergency responders because they ensure team member and responder fitness for duty and also serve as a means to monitor and address team member and responder exposures that cannot otherwise be eliminated due to the nature of emergency response activities.
Fitness and medical surveillance requirements are a highly effective means of reducing work-related injuries, illnesses, and fatalities and improving the health of team members and responders.
NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, 2022 ed., contains provisions for an occupational medical program that is designed to reduce risks and provide for the health, safety, and effectiveness of firefighters while performing emergency operations. It requires a comprehensive medical examination annually for firefighters engaged in the full range of emergency response activities, including firefighting, emergency medical response, HAZMAT response, and technical rescue.
OSHA recognizes that the medical surveillance required by NFPA 1582, Chapter 7, was intended specifically for firefighters exposed to combustion products and NOT for all emergency responders. The provisions for medical screening and surveillance described below account for these concerns. The proposed baseline medical examination focuses on health hazards that are common to all team members and responders, with potential additional requirements based on the particular type and level of service(s) performed, while the proposed medical surveillance requiring a full NFPA 1582-compliant physical is reserved for those team members and responders exposed to combustion products above a specific action level. As explained in Section VII.C., Costs of Compliance, OSHA expects that only structural and wildland firefighters will meet the threshold for the full NFPA 1582 requirements.
Proposed paragraph (g)(1)(i) would require that each WERE and ESO establish minimum medical requirements based on the type and level of service(s) established in paragraphs (c) and (d) of this section.
The medical requirements in proposed paragraph (g) would differ based on the tiers of team members and responders established by each WERE or ESO in accordance with paragraphs (c)(7) and (d)(7), except for those in a support tier (see examples in the Summary and Explanation for paragraphs (c) and (d)) who are excluded from the requirements in paragraph (g) of this section. By tying the medical requirements to the type and level of service(s), proposed paragraph (g)(1)(i) requires the WERE or ESO to establish those requirements, and only those requirements necessary to ensure the health and safety of team members or responders based on the duties they are expected to perform. This proposed provision allows the WERE and ESO flexibility so that team members and responders with less physically demanding duties or who are exposed to fewer hazards may be subject to less stringent medical requirements than team members and responders expected to perform more physically demanding duties or who are exposed to more or more frequent hazards during emergency response incidents.
Paragraph (g)(1)(ii) of the proposed rule would require that each WERE and ESO maintain confidential records for each team member and responder that includes duty restrictions based on medical evaluations; occupational illnesses and injuries; and exposures to combustion products, known or suspected toxic substances, infectious diseases, and other dangerous substances.
OSHA is sensitive to concerns that the medical evaluation may divulge confidential information regarding a responder’s medical condition or may otherwise divulge information that may adversely affect the responder. The proposed requirements are intended to balance team member and responder privacy with the WERE’s and ESO’s need for personal medical information to identify and address occupational hazards by limiting the medical information obtained, as identified in proposed paragraph (g)(2), to the type of information necessary to assess a team member’s or responder’s ability to perform specific tasks based on their health and fitness ability. The use of such medical information is limited to identifying potential health effects or risks related to a team member’s or responder’s ability to perform emergency response activities. The WERE or ESO would be required to maintain the confidentiality of these medical records by storing them in a secure location with restricted access.
Proposed paragraph (g)(1)(iii) would require that each WERE and ESO ensure that medical records maintained under this paragraph are maintained and made available in accordance with 29 CFR 1910.1020, Access to employee exposure and medical records.
These recordkeeping requirements are in accordance with section 8(c) of the OSH Act which authorizes the promulgation of regulations requiring an employer to make, keep and preserve, and make available, such records as the Secretary deems necessary or appropriate for the enforcement of this Act or for developing information regarding the causes and prevention of occupational accidents and illnesses. As explained in 29 CFR 1910.1020(a), access to personal medical records by employees, their representatives, and the Assistant Secretary is necessary to yield both direct and indirect improvements in the detection, treatment, and prevention of occupational disease. OSHA has preliminarily determined that maintenance of and access to the medical records required by this section will help ensure proper evaluation of the team member’s or responder’s health status, facilitate compliance, and assist the agency in enforcing the proposed standard.
Proposed paragraph (g)(2)(i) would require that each WERE and ESO establish a medical evaluation program for team members and responders, based on the type and level of service(s), and tiers of team members and responders established in paragraphs (c) and (d).
The purpose of medical evaluations for team members and responders is to determine, where reasonably possible, if the individual can perform emergency response duties without experiencing adverse health effects and to determine the team member’s and responder’s fitness to use PPE appropriate to their designated duties. As one commenter to the 2007 Emergency Response RFI stated, “[r]equirements should vary based upon the level of physical and mental activity required that must be performed” (Document ID 0024, p. 4). Furthermore, another commenter stated that “NFPA 1582 is not the appropriate standard for use by general industry” since it was “designed for municipal fire fighters” (Document ID 0039, p. 15). Hence, as stated above, this proposed provision would allow the WERE and ESO flexibility to tailor its medical evaluation program so that team members and responders with less physically demanding duties or who are exposed to fewer hazards during emergency responses may have less stringent medical requirements than team members and responders expected to perform more physically demanding duties who are exposed to more or more frequent hazards.
Additionally, each responder routinely exposed to combustion products at or above the threshold set forth in proposed paragraph (g)(3) would be afforded additional medical surveillance as described in that paragraph.
Paragraph (g)(2)(ii) of the proposed rule would require WEREs and ESOs to ensure that, prior to performing emergency response duties, each team member and responder is medically evaluated to determine fitness for duty by a physician or other licensed health-care professional (PLHCP) at no cost to the team member or responder, in accordance with proposed paragraphs (g)(2)(iii) through (vi) of this section.
Each responder who is exposed to combustion products above the action level would also need to be evaluated in accordance with proposed paragraph (g)(3) of this section. The proposed rule would require that medical examinations be made available by the WERE and ESO without cost to team members and responders (as required by Section 6(b)(7) of the OSH Act), and at a reasonable time and place. Paragraph (g)(2)(ii) and the related fitness for duty requirements in proposed paragraph (g)(5), discussed below, ensure each team member and responder is capable of performing their assigned job duties without injury to themselves or their fellow team members or responders. These requirements are consistent with OSHA’s existing Fire Brigades standard, which requires employers to ensure that employees expected to perform interior structural firefighting “are physically capable of performing duties which may be assigned to them during emergencies” (29 CFR 1910.156(b)(2)). Current section 1910.156(b)(2) also specifies that the employer “shall not permit employees with known heart disease, epilepsy, or emphysema, to participate in fire brigade emergency activities unless a physician’s certificate of the employees’ fitness to participate in such activities is provided.” Other OSHA standards contain similar requirements. For example, the HAZWOPER standard requires employers to provide certain emergency responders with medical exams that include an evaluation of “fitness for duty including the ability to wear any required PPE under conditions . . . that may be expected at the work site” and “the physician’s recommended limitations upon the employee’s assigned work” (29 CFR 1910.120(f)(2), (f)(7)). Further, in all cases where respiratory protection is required, either by a substance-specific standard (see, e.g., 29 CFR 1910.1024(g)(1); 1910.1053(g)(1)) or by OSHA’s general Respiratory Protection standard (id. § 1910.134), employees must be medically evaluated to determine their ability to wear a respirator (id. § 1910.134(e)(6)) and must pass a fit test (id. § 1910.134(f)(1)).
Due to the risk of sudden cardiovascular death from strenuous emergency response activities, paragraph (g)(2)(iv) of the proposed rule would require that each WERE and ESO provide additional screening of team members and responders as deemed appropriate by the PLHCP and at no cost to the team member or responder.
The PLHCP has the option of ordering additional testing they deem appropriate based on individual signs or symptoms and clinical judgment. OSHA recognizes that this may result in increased cardiovascular screening of team members and responders beyond those recommended for the general population. This is consistent with NFPA 1582, sections 7.7.7.3.1 through 7.7.7.3.2, which recommends additional cardiovascular assessment at certain risk levels beyond authoritative guidance for general population screening recommended by the ACC/AHA and the United States Preventative Services Task Force (USPSTF). The cardiovascular risk assessment of team members and responders allows the medical provider the ability to focus further screening on only those team members and responders at highest risk of suffering a cardiac event while performing emergency response duties. OSHA has preliminarily determined that compliance with the proposed provision would reduce the risk of sudden death in team members and responders brought on by the stress of their emergency response duties. These additional screenings may include a symptom-limiting exercise stress test with imaging of at least 12 Metabolic Equivalents (METs) as recommended in NFPA 1582, section 7.7.7.3.1.1, for the evaluation of those at intermediate risk of atherosclerotic cardiovascular disease (10 to < 20% calculated risk over the next 10 years), and those with metabolic syndrome, diabetes, or history of coronary artery disease. This is noted as a consideration for intermediate risk asymptomatic adults (class IIb)4 by AHA/ACC as well.
NFPA 1582, section 7.7.6, also recommends a resting electrocardiogram at baseline and annually in those over age 40 or as clinically indicated. ACC/AHA considers resting to be reasonable for asymptomatic patient screening in those with diabetes or hypertension (class IIa)5 and a consideration in those without diabetes or hypertension (class IIb) (Greenland et al., 2010, Document ID 0125, p. e66). This test may detect abnormalities such as left ventricular hypertrophy and arrythmias indicative of increased risk.
NFPA 1582, in the explanatory appendix section A.7.7.7.3.1.1, and ACC/AHA (Arnett et al., 2019, Document ID 0124, p. e613) both consistently mention CAC as a consideration for medical evaluation of emergency response personnel, although NFPA 1582 does not specify indications. Similarly, both organizations emphasize metabolic syndrome as a risk factor.
Additional medical screening might also be required for other medical conditions that are detected in the baseline examination, which may affect a responder’s or team member’s ability to perform their emergency response duties. If the PLHCP suspects a musculoskeletal injury or condition, they may require an x-ray or MRI to determine medical fitness for duty. For respiratory diseases, the PLHCP may require a complete pulmonary function test, exercise stress testing, or methacholine challenge testing to determine medical fitness for duty.
As noted above, the proposed rule would require that all medical evaluations, regardless of type and level of service(s) provided or tiers of team members and responders, include a medical history, physical examination, spirometry, laboratory tests, 5 For ACC/AHA Class IIa medical conditions, ACC/AHA considers it reasonable to perform the procedure or administer treatment.
Provide supporting documentation and data that might establish the appropriate minimum screening. OSHA is also seeking additional data and information on the feasibility of the proposed medical evaluation and surveillance requirements for WEREs and ESOs.
The proposed rule also specifies how frequently medical examinations would be required for team members and responders. In proposed paragraph (g)(2)(v), WEREs and ESOs would be required to provide medical evaluations to team members and responders with an initial (baseline) examination after assignment and repeated every two years thereafter unless the PLHCP deems more frequent evaluations necessary, except for spirometry which would be repeated when deemed appropriate by the PLHCP. The proposed requirement that a medical examination be required at the time of initial assignment is intended to determine if a team member or responder would be able to perform the assigned emergency response duties without adverse health effects. The expectation is that the baseline physical would be performed prior to any entrance into an emergency response training academy or beginning a training program. It also serves to establish a health baseline for future reference. OSHA has set the medical re-evaluation at every two years due to the focus on cardiovascular disease and the speed with which cardiovascular disease develops. The medical re-evaluations are intended to determine if a medical condition has developed that would inhibit safe emergency incident response by team members and responders. Allowing the PLHCP to order more frequent evaluations based on their medical judgment ensures that team members and responders at higher risk of adverse health effects, such as a cardiovascular event, are appropriately monitored to ensure their continued safety and ability to perform emergency response activities.
Paragraph (g)(2)(vi) of the proposal would require that each WERE and ESO establish protocols regarding the length of time that absence from duty due to injury or illness would require a team member or responder to have a return-to-duty medical evaluation by a PLHCP prior to returning to work. Lengthy absences or certain medical conditions can alter a team member’s or responder’s ability to perform essential job tasks.
Proposed paragraph (g)(3) applies to ESOs ONLY and includes additional surveillance for responders who are exposed to combustion products. Paragraph (g)(3)(i) of the proposed rule would require that the ESO provide medical surveillance that includes a component based on the frequency and intensity of expected exposure to combustion products established in the risk management plan in proposed paragraph (f).
Requirements would differ based on exposures. The proposal is consistent with Section 6(b)(7) of the OSH Act, which requires that, where appropriate, medical surveillance programs be included in OSHA standards to determine whether the health of workers is adversely affected by exposure to the hazard addressed by the standard.
Under proposed paragraph (g)(3)(i)(A), the ESO would need to ensure that responders who are, or based on experience may be, exposed to combustion products 15 times or more per year, without regard to the use of respiratory protection, receive medical surveillance at least as effective as the criteria specified in the national consensus standard, NFPA 1582, Chapter 7.
As noted above, OSHA recognizes that the recommendations in NFPA 1582 were aimed at and specifically designed for firefighters who are exposed to combustion products. Thus, although only some of the requirements in NFPA 1582 may be relevant to other team members and responders depending on the types and level of service(s) they provide, OSHA has preliminarily determined that it is appropriate to require the full NFPA 1582 physical for those responders exposed to combustion products above a particular action level.
OSHA is aware that not all exposure incidents are equal and that some of the exposure incidents described above involve a low level of exposure while others involve a higher level of exposure. While some of the individual components in combustion products have PELs, there are no PELs for combined combustion products. The nature of combustion products, being a combination of any number of potentially hazardous substances, often unknown and changing with each emergency incident, as well as the difficulty in measuring such exposures in the emergency response context, would make establishing any such PEL very difficult. Nonetheless, OSHA has determined that despite the varying levels of exposure, both low and high exposure incidents contribute in the aggregate to a responder’s overall exposure to toxic combustion products. Thus, on balance, OSHA has determined that any incident resulting in exposure to toxic combustion products while in the incident hot zone, regardless of the level of exposure, should be counted towards the total number of exposure incidents triggering the action level in this proposed paragraph.
To determine if their responders exceed the action level requiring medical surveillance for exposure, ESOs should review their incident response history. If the average number of exposure incidents is 15 or more a year for an individual responder or a particular tier of responders, then those responders would need the additional medical surveillance.
Proposed paragraph (g)(3)(i)(B) would require ESOs to provide medicalconsultation and ongoing surveillance to responders who, either immediately or subsequently, exhibit signs and symptoms which may have resulted from exposure to combustion products.
Examples include shortness of breath, coughing, or wheezing after an exposure incident. Demonstration of exposure signs and symptoms may indicate a significant exposure event, failure of PPE, a catastrophic event, or some combination thereof and warrants exposure monitoring and medical surveillance. The extension of medical surveillance to responders who demonstrate signs and symptoms of exposure would be required regardless of whether the responder was exposed above the action level. The PLHCP would determine the necessary medical surveillance following the significant exposure event.
Proposed paragraph (g)(3)(ii) would require the ESO to document each exposure to combustion products for each responder, for the purpose of determining the need for the medical surveillance as specified in (g)(3)(i)(A), and for inclusion in the responder’s confidential record, as required in (g)(1)(ii).
ESOs would review previous incident reports to determine a responder’s exposures for the preceding 12 months or from the date when ESOs began keeping such records up to the preceding 12 months. This proposed requirement would ensure the ESO documents exposures in order to comply with the requirements of the proposed rule. OSHA notes, however, that the ESO would not need 12 months of records for a particular responder to determine whether that responder may be exposed above the action level. If the ESO knows, based on experience, that responders in the same tier may be exposed 15 or more times per year, medical surveillance pursuant to paragraph (g)(3) would be required for that responder.
As stated previously, proposed paragraph (g)(3) applies ONLY TO ESOs.
In paragraph (g)(4)(i) of the proposed rule, the WERE and ESO would be required to provide behavioral health and wellness resources at no cost to the team member or responder or identify where resources are available at no cost in their community.
Behavioral health resources provided by a WERE’s or ESO’s health care plan would meet the requirements of the proposed rule. Although community-based resources are preferred, for those communities that do not have the resources available, telehealth resources would also meet the requirements of the proposed rule. Proposed paragraphs (g)(4)(ii)(A)-(D) identify the behavioral health and wellness resources that would need to be included, at a minimum. They are diagnostic assessment, short-term counseling, crisis intervention, and referral for behavioral health conditions arising from the team member’s or responder’s performance of emergency response duties. The conditions that could require referral include substance use disorder, anxiety, depression, suicidality, acute stress reactions, or grief resulting from or exacerbated by the team member’s or responder’s emergency response duties, such as potentially traumatic events or the cumulative emotional strain of emergency response work. These behavioral health conditions may require more intensive interventions than short-term counseling or crisis intervention would provide. Behavioral health resources should be accessible to the team member or responder both on and off-duty.
Proposed paragraph (g)(4)(iii) would require that each WERE and ESO inform team members and responders, on a regular and recurring basis, and following each potentially traumatic event, of the behavioral health resources that are available to them and how to access those resources.
Although resources familiar with the behavioral health aspects of emergency response activities are preferred, it is most important to have resources available for team members and responders to access. ESOs and WEREs should manage team members’ and responders’ expectations concerning available behavioral health resources and provide periodic reminders concerning their availability.
In proposed paragraph (g)(4)(iv), the WERE and ESO would be required to ensure that if the WERE or ESO possesses records of a team member or responders use of behavioral health services, those records are kept confidential. Similar to the privacy and confidentiality concerns about medical evaluations and medical records, OSHA is aware that behavioral health evaluations present similar concerns due to the potential to divulge confidential information regarding a team member’s or responder’s psychological condition that may adversely affect the team member or responder. Proposed paragraph (g)(4)(iv) protects the team member or responder from such unwanted disclosure. Thus, behavioral health record management would be consistent with the requirements for medical record management established in paragraph (g)(1)(iii).
Proposed paragraph (g)(5) focuses on fitness for duty and would require the WERE and ESO to establish and implement a process to evaluate and re-evaluate annually the ability of each team member and responder to perform the essential job functions, based on the type, level, and tier of service(s) established in paragraphs (c) and (d).
The fitness for duty evaluation confirms for the WERE and ESO that the team member or responder can physically perform the job functions required of them at emergency scenes. This requirement differs from being medically cleared to perform emergency response duties as determined by paragraph (g)(2). This requirement requires the WERE or ESO to determine if the team member or responder is physically capable to perform the duties required of them during an emergency response. It is possible for a team member or responder to have no medical limitations to performing emergency response activities and still not be physically able to perform the duties. If the team member or responder does not have the physical capability to perform their assigned duties it not only places them at increased risk of injury or death but also increases the risk for other team members and responders on the emergency scene. During the 2021 SBREFA panel, many SERs expressed concern that the physical fitness for duty requirements would be difficult for team members and responders, especially volunteer responders, to meet (Document ID 0115, p. 17). OSHA understands these concerns. However, the safety of all team members and responders is dependent upon each team member and responder being physically able to perform their assigned duties at an emergency incident. OSHA expects that assessment of the ability to perform essential job functions would be determined during training scenarios in which emergency response activities are practiced under controlled conditions, or during the skills checks required under proposed paragraph (h)(3) of this section. OSHA does not expect a formal testing program to be initiated.
Proposed paragraph (g)(6) applies to ESOs ONLY and includes requirements for a health and fitness program. In proposed paragraph (g)(6)(i), the ESO would be required to establish and implement a health and fitness program that enables responders to develop and maintain a level of physical fitness that allows them to safely perform their assigned functions, based on the type, level, and tier of duty established in paragraph (d).
As the proposed regulatory text indicates, these health and fitness requirements are focused solely on ensuring responders can safely perform their assigned functions. The requirements are aimed at minimizing the risk of occupational injury and illness posed by emergency response activities. OSHA intends these provisions to ensure that responders have the opportunity, means, and knowledge necessary to maintain fitness for duty and to prevent work-related injury and illness.
Proposed paragraphs (g)(6)(ii)(A)-(D) establish the minimum components of the fitness program that the ESO would be required to include.
Proposed paragraph (g)(6)(ii)(A) would require that the fitness program have an individual designated to oversee.
If available, the ESO should designate an individual who has knowledge and skills that would benefit program implementation. To have the desired effect on responder health and fitness, a fitness program needs an individual identified to provide guidance and assistance to responders with the health and fitness program and maintain accountability.
Paragraph (g)(6)(ii)(B) of the proposed rule would require a periodic fitness assessment for all responders, not to exceed every three years.
The purpose of the fitness assessment is to inform the responder on their fitness status and whether their fitness has resources available in the community or on the internet. Topics that may be covered by the health promotion program could include heart disease risk reduction, smoking-vaping and tobacco cessation, healthy blood pressure, physical fitness, safer personal training methods and other ways to minimize risk of muscle breakdown (rhabdomyolysis), nutrition, weight management, the amount and quality of sleep, infectious disease prevention, and behavioral health topics such as stress management. OSHA emphasizes that these education and counseling resources are one element in the broader health and fitness program with the ultimate goal of ensuring the safe performance of emergency response activities.