AOM Informational Packet

After Hours go to Emergency Room of your choice: O’Connor Hospital (408) 947-2666,
El Camino Hospital (650) 940-7055, Regional Medical Center (408) 259-5000, Washington Medical Center (510) 791-3430
LAWRENCEEXPWY.
SANTOMASEXPWY.
GUADALUPE
OAKLANDRD.
PKWY.
BOWERSAVE.
KIFER RD.
CALAVERAS
TASMAN
DR.
BAYSHO
RE
FW
Y.
S.ABELST.
ABBOTT
N.ABELST.
N.1STST.
Great Am. Pkwy.
MONTAGUE
TRIMBLE RD.
EL CAMINO REAL
WALSH AVE.
SCOTT BLVD.
CENTRAL EXPWY.
Santa
Clara
San
Jose
Milpitas237
101
101
101
680
680
680
280
880
87
880
880
SENTERROAD
CURTNER AVE.
ALMA AVE
TULLY ROAD
STAUFFER BLVD.
MONTEREYROAD
The Plant
Across the street from Gold’s Gym
Milpitas
315 S. Abbott Ave.
Milpitas, CA 95035
Ph: (408) 790-2900
Fax: (408) 790-2912
www.allianceoccmed.com
Monday - Friday 7AM - 7PM
Work-Related Injuries & Physicals
Santa Clara
2737 Walsh Ave.
Santa Clara, CA 95051
Ph: (408) 228-8400
Fax: (408) 228-8401
San Jose
1901 Monterey Rd., Ste 10
San Jose, CA 95112
Ph: (408)) 477-8080
Fax: (408) 477-8081
Next to Denny’s on the right side of street
Across the street from Carl’s Jr.
BOWERSAVE.
W. CALAVERAS
SERRA
BLVD.
TASMAN
DR.
McCARTHY
BLVD.
ABBOTT
S.ABELST.
S.MAINST.
S.MILPITASBLVD.
N.MILPITASBLVD.
N.ABELST.
KIFER RD.
WALSH AVE.
2737 WALSH AVE.
1901 Monterey Hwy
315 S. ABBOTT AVE.
SENTERROAD
LAWRENCEEXPWY.
CURTNER AVE.
ALMA AVE
TULLY ROAD
STAUFFER BLVD.
MONTEREYROAD
CENTRAL EXPWY.
880
880
87
237
87
The Plant
Milpitas
Santa Clara
San Jose
Alliance Occupational Medicine

Date 11/24/09 Alliance Occupational Medicine-ML Page 1
315 South Abbott Avenue
Milpitas, CA 95035
(408) 790-2900, Fax: (408) 790-2912
Work Status Summary
Company: Altera Corp
101 Innovation Drive
San Jose, CA 95134
Attention: Vikki Norton
Telephone: (408) 544-6788
Fax: (408) 544-8303
vnorton@altera.com
Provider: Azar, Dan R. MD MPH (Milpitas)
Visit Date: 11/24/09 Time In: 2:13PM Out: 3:01PM
Employee: Sarah Ellis
707 Continental Cir #123
Mountain View, CA 94040
Department:
Ident: xxx-xx-9306 DOB: 5/31/68
Job Title: Staff Program Mgr
(408) 839-6068Phone:
Purpose: 1 First Medical Visit (WC)
Insurance Information
St Paul Travelers MN Contact: Jane Cunningham
P.O. Box 64907
St. Paul, MN 55164-0907 Fax: 877-288-2793
Ext:800-842-3073Telephone:
Presenting Problem
Date of Injury: 11/20/09 Case Number:2009-00009 Claim Number:A5K6382
picking up box, extreme (8 out of 10) pain in lower left of spine back. Pain in lower back thru Friday,
Sat Pain shoots thru left quad. Mon, pain shots thru left quad and left leg felt heavy. Rx from my
primary- 800-600mg Ibuprofen x3 daily (started last night)
Diagnosis
847.2 Sprain / Strain Lumbar Spine (Lower Back)
Current Work Restrictions
Acute Injury / Illness Starting: 11/24/09 Continuing
Rehab Next Appt If Not Better Starting: 11/24/09 Continuing
Recordable Starting: 11/24/09 Continuing
Estimate 4-6 Weeks Until P&S Starting: 11/24/09 Continuing
Work Status
Work Status: Released for Full Duty As Of: 11/24/09
2 Medical ReCheck (WC) Braren, Maria NP (Milpitas)Follow-up Appointments: 12/01/09 at 8:30AM
SAMPLE WORK STATUS REPORT
SAMPLE WORK STATUS REPORT
St Paullllllllllllllll Tr
P.O. Boxoxoxoxoxoxoxoxoxox 6
St. Paululul,,,,,,,, MN
Date of Injury:
Ramesh, Jaishri MD
SAMPLE WORK STATUS
SAMPLE WORK STATUS

DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESSSTATE OF CALIFORNIA
Within 5 days of initial examination, for every occupational injury or illness, send two copies of this report to the employer's workers' compensation insuranc e carrier or the insured employer. Failure to
file a timely doctor's report may result in assessment of a civil penalty. In the case of diagnosed or suspected pesticide poisoning, send a copy of this repor t to the Division of Labor Statistics and Research,
P.O. Box 420603, San Francisco, CA 94142-0603, and notify your local health officer by telephone within 24 hours.
1. INSURER NAME AND ADDRESS
2. EMPLOYER NAME
3. Address No. and Street City Zip
4. Nature of business (e.g., food manufacturing, building construction, retailer of women's clothes)
5. PATIENT NAME (first name, middle initial, last name) 6. Sex 7. Date of
Birth
PLEASE DO NOT
USE THIS
COLUMN
8. Address: No. and Street City Zip 9. Telephone Number
10. Occupation (Specific Job Title) 11. Social Security Number
12. Injured at: No. and Street City County
13. Date and hour of injury
or onset of illness
14. Date last worked
15. Date and hour of first
examination or treatment
16. Have you (or your office) previously
treated patient?
Patient please complete this portion, if able to do so . Otherwise, doctor please complete immediately. Inability or failure of a patient to complete this portion shall not affect his/her right to worker's;
compensation under the California Labor Code.
17. DESCRIBE HOW THE ACCIDENT OR EXPOSURE HAPPENED . (Give specific object, machinery or chemical. Use reverse side if more space is required.)
18. SUBJECTIVE COMPLAINTS (Describe fully. Use reverse side if more space is required.)
19. OBJECTIVE FINDINGS (Use reverse side if more space is required.)
A. Physical Examination
B. X-ray and laboratory results (State if none or pending.)
20. DIAGNOSIS (If occupational illness, specify etiologic agent and duration of exposure) Chemical or toxic compounds involved?
21. Are your findings and diagnosis consistent with patient's account of injury or onset of illness?
22. Is there any other current condition that will impede or delay patient's recovery?
23. TREATMENT RENDERED (Use reverse side if more space is required.)
24. If further treatment required, specify treatment plan/estimated duration.
25. If hospitalized as inpatient, give hospital name and location.
26. WORK STATUS - Is patient able to perform usual
work?
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation
for the purpose of obtaining or denying worker's compensation benefits or payments is guilty of a felony.
Form 5021 (Rev. 4)
1992
Doctor's name and degree (please type)
Address
IRS Number
Telephone Number
Mo. Day Yr.
Mo. Day Yr. Hour Mo. Day Yr.
Case No.
Industry
County
Mo. Day Yr. Hour
Occupation
Return Date/Code
ICD-9 Code:
If "no", please explain.
If "yes", please explain.
Specify restrictions:
Modified work
If "no", date when patient can return to:
Regular work
Hospitalization
Disease
Hazard
Age
Date admitted Estimated stay
2009-00009
St Paul Travelers MN P.O. Box 64907, St. Paul, MN 55164-0907
Altera Corp
101 Innovation Drive, San Jose, CA 95134
programmable chips
Sarah Ellis 05/31/1968
707 Continental Cir #123, Mountain View, CA 94040
000-00-9306
(408)839-6068
Female
Staff Program Mgr
101 Innovation Drive San Jose Santa Clara
07:00AM11/20/2009
02:13PM11/24/2009 No
picking up box, extreme (8 out of 10) pain in lower left of spine back. Pain in lower back thru Friday, Sat Pain shoots thru left quad. Mon, pain shots thru left quad
and left leg felt heavy. Rx from my primary- 800-600mg Ibuprofen x3 daily (started last night)
SEE ADDENDUM
SEE ADDENDUM
none
847.2No
847.2 = Sprain / Strain Lumbar Spine (Lower Back)
Yes
No
SEE ADDENDUM
see 23
Yes
Rehab Next Appt If Not Better; Acute Injury / Illness; Recordable; Estimate 4-6 Weeks Until P&S
11/24/2009
408-790-2900315 S. Abbott Ave., Milpitas, CA 95035
5164-0907St Paul Travelers MN P.O. Box 64907, St. Paul, MN 55164-09075164-0907
SAMPLE DOCTOR'S FIRST REPORT
Doctor's Signature CA License Number A51723
Ramesh, Jaishri MD(Milpitas) 77-0572487

DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS - ADDENDUM
11/24/200911/20/2009 Treatment: 2009-00009Sarah Ellis DOI:
18. Subjective Complaints:
ADDENDUM TO DOCTOR'S FIRST REPORT:
Translator: none
Current Meds: None relevant to injury.
Drug Allergies: NKDA
Denies history of Ulcer or NSAID-related gastritis / GI upset.
Denies being pregnant or breastfeeding.
Employee states while at work 4 days ago had the sudden onset of left sided low back pain radiating to left thigh after lifting
a box weighing approximately 50 lbs (containing 2 monitors). The EE went home to rest and applied heat. She returned
later that day for a meeting. Over the weekend her symptoms persisted but did not worsen. Yesterday she went to her
personal MD at PAMF and was advised to use Ibuprofen 800, apply ice and file a WC claim with her employer (which she
did this morning).
Currently the EE reports only slight low back pain; she has momentary intense radiating anterior thigh pain which is
somewhat electrical in nature, and less intense aching or heaviness of the thigh.
Denies lower leg pain or sensory changes, bowel or bladder changes, or saddle paresthesias.
PAST MEDICAL HISTORY / REVIEW OF SYSTEMS:
Except as described above, patient denies prior injury to back or back pain in past.
Except as described above denies pre-DOI symptoms, restrictions or limitations.
Except as described above denies recent medical or chiropractic treatment for current condition.
Except as described above denies hobbies, sports or nonindustrial activity as cause or contributor to injury.
19-A. Objective Findings:
BP: 120/82
THORACO-LUMBRO-SACRAL SPINE:
normal examination except decrease in ROM due to pain and minimal tenderness along left PSIS
Normal gait, no foot drop
Normal curvature and posture
No edema, no discoloration, no scar, no open wound
Range of motion @ thoraco-lumbar-sacral spine (estimated):
Flexion at the waist: 80/90
Thoracic Spine Rotation Right: 30/30
Thoracic Spine Rotation Left: 30/30
Lumbar Extension: 5/20
Lumbar Lateral Flexion Right: 30/30
Lumbar Lateral Flexion Left: 30/30
Parathoracic and paralumbar muscles nontender
Sciatic notches nontender
Lower extremities demonstrate full strength and sensation
No palpable spasm
Deep tendon reflexes intact bilaterally at knees and ankles
Midline thoraco-lumbar-sacral spine nontender
Seated straight leg raise bilaterally negative
Additional Assessment:
847.2 Sprain Lumbar Spine (Lower Back)

DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS - ADDENDUM
11/24/200911/20/2009 Treatment: 2009-00009Sarah Ellis DOI:
23. Treatment Rendered / 24. Treatment Plan:
ADDENDUM TO DOCTOR'S FIRST REPORT:
35 minutes spent face to face with over 50% spent on patient counseling.
DISCUSSION/DIFFERENTIAL DIAGNOSES:
Acute strain of low back with referred pain - possible piriformis syndrome but not consistent with herniated disc or frank
lumbar radiculopathy.
Treat conservatively; patient declines my offer of physical therapy at this time; home exercise sheets reviewed with patient
and dispensed.
CAUSATION:
Mechanism of injury and physical examination are consistent with a work-related injury.
At this point, no issues of causation or apportionment identified.
PATIENT EDUCATION:
Diagnosis, treatment options and prognosis explained to employee.
Work recommendations reviewed and given self-care instructions.
Importance of compliance with restrictions and treatment emphasized.
Questions regarding treatment answered.
PATIENT CONSENTS TO THE FOLLOWING TREATMENT:
Dispense Ibuprofen 800mg 1 tablet 2-3/day with food or milk, #40; discontinue if GI upset or melena/hematochezia arise.
Dispense Cyclobenzaprine (Flexeril) 10mg 1-2 tab at bedtime if needed for spasm dispense #20; cautioned about sedation.
Continue ice/heat as needed for comfort.
If improved less then expected at next visit: start Physical Rehab.
If improved at next visit monitor until MMI, and D/C then or sooner if appropriate.
RECORDABLE, INDUSTRIAL INJURY
No Permanent Disability Expected
WORK STATUS:
Full duty
FOLLOW-UP:
Recheck 1 Week
Patient warned to follow up sooner (no appointment needed) if condition worsens or interferes with ability to work as
prescribed above.
As requested, designated employer representative contacted by telephone to coordinate medical and disability management.
I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated
Labor Code 139.3
Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be
subject to fines and confinement in state prison.
________________________________________________
Medical Director
Alliance Occupational Medicine
Jaishri Ramesh M.D. CA Lic # A51723
Dictated 11/24/2009 but not reviewed until signed / Transcribed byJR

315 S. Abbott Ave. Milpitas ♦ Ph: (408) 790-2900 ♦ Fax: (408) 790-2912
2737 Walsh Ave. Santa Clara ♦ Ph: (408) 228-8400 ♦ Fax: (408) 228-0456
1901 Monterey Rd. Ste 10 San Jose, CA. 95112 ♦ Ph: (408) 477-8080 ♦ Fax: (408) 477-8081
Marlowe Magallanes MD License # A102136 has been treating injuries since
2008. Dr. Magallanes received his medical degree from the University of the
Philipines and is Board Certified in Internal Medicine. He completed his
postdoctoral training at Overlook Hospital in New Jersey, the primary academic
and clinical affiliate of Mount Sinai School of Medicine and The Mount Sinai
Hospital. Dr. Magallanes is also fluent in Tagalog and happily married with 3
sons. He is also NCRME certified for DOT physicals # 6968979761
Jaishri Ramesh MD License # A51723 has been working in occupational medicine
since 1995. She received her Medical degree from Bangalore Medical College. She
completed her internship in Internal Medicine at St Vincent Hospital in Portland
Oregon and residency in Internal Medicine at Kaiser in Santa Clara, CA. She
became board certified in Internal Medicine in 1994. Dr. Ramesh is fluent in
English, Kannada, Marathi, Hindi, and Tamil. Dr. Ramesh is also a Certified
Medical Review Officer and the lead physician in our Santa Clara facility. Dr.
Ramesh is also NCRME certified for DOT physicals # 6408767753.
Tom Zdimal, P.A. License #PA10590 has been practicing as a Physician’s
Assistant in Occupational Medicine in this area since the late nineteen eighties. Tom
graduated from the George Washington University Medical School Physician’s
Assistant program. Tom served as a Preventative Medicine Specialist in the United
States Air Force. Tom’s professionalism, knowledge, demeanor, and
communication skills make him invaluable in the occupational health arena. He is
also NCRME certified for DOT physicals # 7211965891.
.
Christine Nga Le, P.A. License #PA16365 has been practicing as a Physician’s
Assistant in Occupational Medicine in this area since 2005. Christine graduated
from Massachusetts College of Pharmacy and Allied Health Sciences Physician’s
Assistant program. She speaks English, Vietnamese and some Spanish. She is also
NCRME certified for DOT physicals # 5638677379

Edward Cooper, M.D. License #G32478 has worked in occupational
medicine and urgent care since 1976. Dr. Cooper graduated from Oklahoma
State University School of Medicine and completed his internship at
Washington Hospital Center in Washington D.C. He is also certified in
completing INS examinations and NCRME Certified for DOT Physicals #
4167314950
Maria Braren, N.P. License #12680 has been working in occupational
medicine since 2003. She graduated from San Jose State University with a
Masters of Science in Nursing. Maria completed her undergraduate training at
Southern Connecticut State University. Maria is Board certified as a Family
Nurse Practitioner. She is also NCRME Certified for DOT Physicals #
774036268
Sapna Sheth Rajput, D.O. License #20A9578 has been working in
occupational medicine since 2009. She received her Bachelors of Science in
Genetics from the University of California at Davis. She graduated from the
Chicago College of Osteopathic Medicine in May 2004. She completed her
residency in Family Medicine through the San Jose-O’Connor Hospital Family
Medicine Residency Program which is affiliated with Stanford University
School of Medicine. She is Board Certified in Family Practice. Dr. Sheth
Rajput is proficient in Intermediate Gujarati. She is also NCRME Certified for
DOT Physicals # 9535372382

Lynda Lee Kay M.D., License # A52407 has been practicing Occupational
Medicine since 2005. She graduated from the Institute of Medicine in Burma. Dr.
Kay completed a Family Practice Residency from the University of Louisville,
KY. Dr. Kay is a member of the Santa Clara County Medical Association and the
United States Burmese Medical Association. Dr. Kay speaks Burmese and
Chinese as well.
Henry Poon, MD License #687335 has worked in occupational medicine since
2004. He received his medical degree from Tufts University School of Medicine.
He earned his Masters Degree in Public Health and Masters in Business
Administration from the University of North Carolina at Chapel Hill. Dr. Poon
completed a residency in occupational medicine from Emory University where he
was chief resident. Dr. Poon is Board Certified in Occupational Medicine, a
Certified Medical Review Officer, and a Certified Medical Examiner on the
National Registry. Dr. Poon is fluent in English and Chinese.
Satish K. Sharma M.D., License # A45180 has been practicing Occupational
Medicine since 1988. He graduated from L.L. RM Medical College. He completed
his Residencies in Family Practice and Internal Medicine from Meharry/Hubbard
Medical College & Hospital in Nashville, TN. He completed his Residency in
Neurology and Fellow in Electrophysiology from the University of California at
Davis. He is Board Certified in Internal Medicine and Board Eligible in
Neurology. He is also a National Registry Certified Medical Examiner for driver
exams. He is fluent in English, Hindi and Punjabi.

James Petros, M.D. License #A90732 is dual board-certified in Physical Medicine
& Rehabilitation (Physiatry) and Internal Medicine. Dr. Petros specializes in pain
management. He provides consultation and multi-faceted care to patients whose
pain does not respond to conservative measures. He performs EMGs and
interventional procedures, such as epidurals. Dr. Petros completed his B.S. in
Biology at Santa Clara University, graduating magna cum laude. He then attended
Tulane Medical School, obtaining his M.D. with high honors. Dr. Petros completed
his Internal Medicine residency at CPMC/UCSF and his Physiatry residency at
Stanford. He was voted as one of America's Top Physicians by the Consumer
Research Council in 2009. Dr. Petros is fluent in Aramaic, Farsi, and French. He is
a Qualified Medical Evaluator for the State of California.
Samir Sharma, M.D. License #A72062 is a general orthopedist with an emphasis
on knee, shoulder and hand surgery. Dr. Sharma completed his medical training
and Residency in Orthopedics at Wayne State University. Dr. Sharma also
completed a sports medicine fellowship in Lake Tahoe performing over 400
operative cases. Diplomate American Board of Orthopaedic Surgery, Fellow
American Academy of Orthopaedic Surgeons, Fellowship trained Sports Medicine,
and State of California Qualified Medical Evaluator.
Prasad G. Kilaru, M.D. License #A60104 is a plastic and reconstructive hand
surgeon, who is Board Certified in Plastic Surgery. Dr. Kilaru completed his Surgical
Residency at Baystate Medical Center and his Plastic Surgery Residency at USC/LA
County. He completed a Hand/Microsurgery Fellowship at USC Medical Center. He
completed his MBA program for Executives through the Wharton School of
Business. Dr. Kilaru has been treating traumatic and repetitive industrial injuries of
the hand since 2001. Dr. Kilaru also has expertise in wound care, scar management,
burn treatments and other aspects of plastic and reconstructive surgery in addition to
hand surgery.

Bruno Kovacic - BioFunction® LLC Mr. Kovacic is the founder and managing
member of BioFunction® LLC, a forensic disability consulting company, which
is working in cooperation with Alliance Occupational Medicine to provider work
capacity examinations and functional restoration. Bruno brings more than 25
years of progressive healthcare & occupational medicine experience including:
conducting sophisticated Evidentiary Forensic Disability Examinations for more
than 400 claimants in private, public and government sectors, designing
advanced intra-data validation, behavioral & discomfort factoring software used
to quantify chronic pain, providing written med-legal opinions for ergonomic,
personal injury and workers’ compensation claims in California, the Division of
Workers’ Compensation Appeals Board, the State of Hawaii’s Disability
Compensation Division, and Canada’s ICBC, creating and designing a web-
based medical restriction / job task matching software application to safely
match limited duty employees to modified tasks in the work environment for the
U.S. largest employer, and developing the industries first ergonomic risk sorting
algorithm to quantify frequency, duration and severity of early symptom patterns
associated with cumulative trauma / repetitive motion injuries. Mr, Kovacic is a
peer reviewed published researcher in Evidence-Based Functional Restoration.
Mr. Kovacic also holds credentials as a medically trained Certified Ergonomic
Compliance Director and is one of two Certified ERGOS® Trainers in the U.S.
Jeffrey T. Holmes MD License #G48778 is an Orthopedic Surgeon and has
experience in occupational medicine for more than twenty years. Dr. Holmes
completed his undergraduate and graduate studies at Stanford. He completed
Preclinical studies at the Royal College of Surgeons in Ireland. He is a graduate from
Harvard University Medical School. He completed his Internship and Residency in
Orthopedic Surgery at Stanford University. Dr. Holmes has specialty expertise in
shoulder, knee, and hip issues. He treats a wide variety of industrial and sports
injuries. Dr. Holmes is a State of California Qualified Medical Evaluator as well.

Physical Therapists, Hand Therapists & Physical Therapy Assistants:
Vicki Jaw, D.P.T., License # has been working in physical therapy since
2012. Vicki received her BS degree at the University of Michigan, with
an emphasis in Movement Science and Kinesiology. She received her
Doctor of Physical Therapy degree from the University of Colorado and
has received her clinical training in the areas of Orthopedics, Sports
Medicine and Pediatrics.
Elmma Pena, D.P.T., License # PT39084 has been working in physical
therapy since 2012. Elmma received her BS degree in Kinesiology at Cal
State University in Hayward. She received her Doctor of Physical Therapy
degree from the University of St. Augustine in San Marcos and has
received her clinical training in the areas of Orthopedics and out patient
therapy. She is fluent in Spanish as well.
Lucy Austin PTA License #AT1228 has worked as a physical therapy
assistant in occupational medicine since 1994. Lucy received her Physical
Therapy Assistant degree from DeAnza College. Lucy has received
additional training in kinesiotaping, pilates for rehab, and edema differential
diagnosis and treatment. She is also certified ergonomics assessment
specialist.

Chiropractors (cont.)
James Grubinskas DC License #DC25571 has worked in occupational
medicine since the late nineties. He received his Doctor of Chiropractic
Degree from the Palmer College of Chiropractic in San Jose. Dr.
Grubinskas focuses on home exercise programs and works under the
direction of our primary treating providers to expedite recovery from work
related injuries. Dr. Grubinskas is also a Certified Ergonomics Assessment
Specialist
Richard Chau DC, QME License #DC21183 has worked in occupational
medicine since 1991. Richard attended the University of Miami
studying Biology. He received his doctor of chiropractic degree from Life
West Chiropractic College in Hayward. Richard is a Certified Ergonomics
Assessment Specialist and a Qualified Medical Evaluator. Richard
is trilingual, fluent in Spanish and Cantonese Chinese.
Miral Patel License #PT41286 has worked in occupational medicine since
2013 and has been working in physical therapy since 2009. Miral received
her Bachelor of Physiotherapy at SNDT University in Mumbai, India. Miral
received additional training in orthopedic and neurological treatment during
her clinical rotations. She’s taken courses in Sports Medicine, Soft Tissue
Mobilization, Essential Taping Techniques, and Low Backache Syndrome.
Miral is fluent in English, Hindi, and Gujarati.

First Aid/Non-Recordable
FIRST AID VS MEDICAL TREATMENT
Employers may elect to pay directly for claims that are deemed “first-aid” or “non-
recordable. We follow the CAL-OSHA recommendations per Standard 1904.7 effective
January 1, 2002 for designation of “first aid” or “non-recordable” as outlined below.
• Use of nonprescription medication at nonprescription strength
• Administration of tetanus vaccine
• Cleaning, flushing or soaking wounds on the surface of the skin
• Using wound coverings such as bandage (s), Band-Aids or gauze pads,
or using butterfly bandages or Steri-Strips
• Using hot or cold therapy
• Using any non-rigid means of support (such as elastic bandages, wraps,
non-rigid back belts)
• Using temporary immobilization devices while transporting an
accident victim
• Drilling of a fingernail or toenail to relieve pressure, or draining fluid
from a blister
• Using eye patches
• Removal of foreign body from the eye using only irrigation or cotton
swab
• Removal splinter or foreign material from areas other than eye by
irrigation, tweezers, cotton swabs or other simple means
• Using massage
• Using finger guards
• Drinking fluids for relief of heat stress
• Negative x-ray diagnosis (use of diagnostic procedures such as x-rays
or blood tests for diagnostic purposes only)
Medical Treatment/Recordable
• Use of prescription medication or non-prescription medication in prescription strength
• Restriction of work or motion beyond the day of the injury
• Injury requiring transfer to another job
• Injury causing days away from work
• Administration of other (non-tetanus) vaccines such as Hepatitis B vaccine or rabies vaccine
• Use of wound closing devices such as sutures (stitches) or staples
• Using devices with rigid stays or other systems designed to immobilize parts of the body
• Physical therapy or chiropractic treatment
• Loss of consciousness
• Significant injury or illness diagnosed by a licensed health care professional such as: cancer, chronic irreversible
disease, fractured or cracked bone, punctured eardrum, or progressive disease.
• Positive x-ray diagnosis
• Hearing loss of more than 10 decibels
• Death
2737 Walsh Ave. Santa Clara, CA. 95051 | phone 408.228.8400 | fax 408.228.0456
315 S. Abbott Ave. Milpitas, CA. 95035 | phone 408.790.2900 | fax 408.790.2912

DMV TIPS FOR COMMERCIAL DRIVERS
REGULATIONS REGARDING CERTAIN MEDICAL
CONDITIONS MAY AFFECT YOUR LICENSE
ONLY NATIONAL REGISTRY CERTIFIED
MEDICAL EXAMINERS CAN ASSESS YOUR
MEDICAL CAPACITY TO DRIVE AS OF 5/21/14
1 High Blood Pressure (Hypertension): Qualified for 1
year if you are currently on medication or had been
treated in the past. BP needs to be below 139/89 on the
exam date to be qualified.
2 Diabetes: Qualified for 1 year. You might need a
clearance letter from your doctor to confirm that your
blood sugar level is well controlled with no complication
or hypoglycemic episodes. INSULIN treatment is an
automatic disqualification for commercial drivers.
You may be disqualified if your blood sugar is not well
controlled.
3 Obesity: At risk for obstructive sleep apnea (OSA) if you
have the following conditions: BMI 35 and above, neck
size >17 cm (male) / >15.5 cm (female), small airway,
Hypertension, Diabetes, Hypothyroidism, age 42 and
above, experienced a single-vehicle crash...etc. You will
need to do a sleep study.
4 Obstructive Sleep Apnea: Qualified for 1 year. You
need to show proof that you use your CPAP machine
regularly. Have your doctor print out usage data from
your CPAP machine. To be qualified your compliance
data must show at least 4 hours per day of use on 70% of
days.
5 Asthma/ Lung Disease/Smokers over the age 35:
requires a spirometry to measure lungs function.
6 Heart Disease: Qualified for 1 year. You may need a
clearance note from your cardiologist stating your current
heart condition/function, applicable test reports, and your
ability to operate CMV.
7. Heart Surgery: Depending on the type of
surgery you may be temporarily
disqualified for a short period before you
can be qualified to drive again. You will
need a clearance letter from your
cardiologist stating your heart condition/
function, and your ability to safely operate
CMV.
8 Stroke: Disqualified at least 1 year. Need
clearance from neurologist.
9 Hearing Impairment: You may need
hearing aid if you do not meet DOT
requirement. You must have no more than
40 decibels hearing loss on the better ear.
You will be temporarily disqualified for
further testing by your ear specialist
(audiologist).
10 Vision Impairment: You may need glasses
if you do not meet DOT requirement for
both eyes. Your vision should be less than
or equal to 20/40 in each eye. If you do not
meet requirement, you will be temporarily
disqualified until corrective lens provided.
11 Work Restriction: for any medical
conditions will be disqualified as DOT
requires drivers to have a full physical and
mental capacity to be a commercial driver
and be able to do strenuous work.
12 Mental Disorder: You may need clearance
from your psychiatrist to comment on your
current mental condition and whether it
affect your judgment, attention,
concentration, and ability to operate safe
CMV.
13 Dementia: Disqualified
14 Dizziness and Vertigo: You may be
disqualified for a short period and requires
a clearance from your doctor stating that
you are symptom free for at least 2 months.
Santa Clara Clinic
2737 Walsh Ave.
Santa Clara, CA. 95051
Phone: (408) 228-8400
Fax: (408) 228-8401
Milpitas Clinic
315 S. Abbott Ave.
Milpitas, CA. 95035
Phone: (408) 790-2900
Fax: (408) 790-2912
San Jose Clinic
1901 Monterey Rd. Ste 10
San Jose, CA. 95112
Phone: (408) 477-8080
Fax (408) 477-8081

Information Technology Solu-
For More Information: (408) 332-5410
tfiack@allianceoccmed.com
Humans come in many shapes and sizes, as
do respirators. This results in a wide variability
of physical dimensions and features of both
people and respirators. The ability of a respi-
rator to form a satisfactory seal or barrier be-
tween the wearer and the contaminated envi-
ronment may be significantly affected by these
variables. If the respirator-user math “fit” is not
checked, an unsatisfactory seal may unknow-
ingly exist. This could allow excessive leak-
age of airborne contaminants into the wearer’s
breathing zone, even though user is wearing a
respirator correctly selected for the application.
A fit test is used to assess whether a specific
type, model, and size of respirator can ade-
quately fit a specific individual.
There are two basic types of fit tests: 1. qualitative
(QLFT) and 2. quantitative (QNFT). The qualita-
tive test is a pass/fail test relying on the subject’s
voluntary or involuntary response to a challenge
agent:; i.e. smell or irritation. The Alliance staff
encourages the use of the more sophisticated
quantitative fit test. The quantitative fit test is an
objective test that measures the particulates in the
surrounding air vs. what a person is breathing in
through the respirator. The instrumentation is
typically capable of measuring fit factors of 10,000
or higher. Our staff will perform a quantitative fit
test of the individual workers and their personal
respirator. We can perform this testing at our con-
venient Santa Clara Clinic or at your site. This
service is combined with the Pulmonary Func-
tion Test and Physical/Medical Review.
Fit Test All Masks
Including:
• Half Mask APR
• Full Mask APR
• PAPR
• SCBA
• N95
Serving the Following Indus-
tries:
• Aerospace & Defense
• Agriculture
• Automotive
• Biotechnology
• Chemicals
• Construction
• Electric Power
• Emergency Responders
• Energy
• Firefighters
• Health Care
• Law Enforcement
• Manufacturing
• Mining & Drilling
• Nuclear Power
• Oil & Gas
• Pharmaceuticals
• Transportation & Logistics
Alliance Now Offers Quantitative
Fit Testing with the State of the
Art PortaCount Plus

ERGONOMICS PROGRAM MAN-
AGEMENT
We will help you build a sustainable
ergonomics process that is supported
by the infrastructure and values of your
organization, along with developing an
action plan that will accelerate your
success.
ERGONOMICS TRAINING
From basic ergonomics awareness
training to engineering workshops, our
hands-on approach ensures each class
is custom matched to your needs
WORKPLACE ASSESSMENTS
From mini individual workstation as-
sessments to full ergonomic evaluations
our qualified staff will identify issues and
offer specific solutions with an empha-
sis on individual responsibility, behav-
iors, postures, and techniques.
Why is Ergonomics important for your bottom line?
The lack of Ergonomics in the workplace leads to these costs:
• How much you spend on your employees long term health and
safety.
• How much you spend on boosting employees’ and company mo-
rale.
• Turnover
• Absenteeism
• Productivity
• Product quality (how much do mistakes cost?)
• Compensation Claims
W W W.AL LIANC EOCCM ED.COM2737 Walsh Ave. Santa Clara, CA. 95051 Ph: (408) 228-8400 Fax: (408) 228-0456
315 S. Abbott Ave. Milpitas, CA. 95035 Ph: (408) 790-2900 Fax: (408) 790-2912
S E R V I C E S A V A I L A B L E
Effective ergonomics programs assure high productivity, avoidance of
illness and injury risks, and increase satisfaction among your workforce.
Our certified ergonomists combine practical industry experience with the
skills of professional services delivery. We are experts in workplace im-
provement. Big project or small, we bring tangible benefits to you and
your company at every step. Whether you need to deploy a global ergo-
nomics initiative or a single risk assessment, we partner with you to
achieve your goals. We listen well, work hard, and evaluate ourselves
based upon your success.
Ergonomics is the science of fitting workplace conditions and job
demands to the capabilities of the working population.

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