Pulmonary Disorders: Asthma

sec_arr Appendix D

Treating Physician Evaluation Form for the Law Enforcement Officer with Asthma

NOTE TO POLICE PHYSICIAN: The following form is presented as an option for obtaining necessary information. Another option is review of medical records.

Examinee Name:
_________________________________________________________ DOB:___________

You are being asked to evaluate this individual for their asthma condition. It is essential that this person undergo an individualized assessment of his/her pulmonary disorder to assist in determining whether the individual’s condition permits safe and effective job performance.

This evaluation is based on guidance from the American College of Occupational and Environmental Medicine (ACOEM).

I. Introduction:
The well-educated and well-motivated LEO with asthma may be capable of safe and effective job performance. An individualized assessment of the LEO’s or applicant’s asthma should be performed including an assessment of the following:

  • Detailed history and physical examination
  • Standardized test results (e.g., Spirometry/PFT) when indicated
  • Diagnosis (classification and causation)
  • Evaluation of treatment plan for optimization
  • Nature of provocative agents/conditions
  • Frequency of exacerbations and last exacerbation occurrence
  • Medication regimen
  • Response to medication regimen
  • Complications or activity-limiting side-effects from medication regimen
  • Compliance with therapy
  • Risk of recurrence
  • Planning for on-going surveillance

Assessing the inability to safely and effectively perform essential law enforcement job functions, or of experiencing a sudden impairment rendering them unable to do so, is the major concern in evaluating law enforcement officers with lung diseases.

Law enforcement activities involve several issues that need to be considered in regard to those with asthma/bronchospastic disorders and the risk of exacerbations:

  • Unanticipated extreme physical activity that, if not executed properly, could result in death or severe disability to others or the law enforcement officer.
  • Exposure to environmental provocative agents – e.g., dust, allergens, cold, dry air.
  • Exposure to tear gas and pepper spray

II. Assessment
I am a pulmonologist or a physician experienced in the diagnosis and treatment of asthma. __Yes __No

1. The examinee has been under my care for asthma since _________________.

2. I have reviewed outpatient and in-patient medical record(s) of the last 1 year or since date of diagnosis (whichever is shorter) __ Yes __No
If NO, please explain
Please provide available records to the police physician for review.

3. Date asthma diagnosed:____________________________

4. Has this person had any objective testing (pulmonary function testing, challenge testing, etc.) for asthma within the past year? __ Yes __ No
If YES, please supply a copy of the results.

5. Does this person meet the criteria of being well-controlled based on the EPR-3 criteria? (See copy of EPR-3 classification table at end of this form)
__ Yes __ No
If YES, how long have they met the criteria of being well-controlled?

6. Medication Regimen
a. Current asthma medications:

b. When was the last time the medication regimen was changed?

7. Can this individual participate in high intensity physical activities (equivalent to 12 METs)? __ Yes __ No
If “NO” please explain.

8. Has this individual been educated in asthma and thoroughly informed of the risk of recurrence and the importance of treatment compliance?
__ Yes __ No

9. Is the examinee’s activity limited by:

Weather conditions? __ Yes __ No

Exposure to environmental asthma triggers or specific allergens?
__ Yes __No

If YES, please specify:

Signature of Physician _________________________________________________
Date _________________
Printed name of Physician _______________________________________________
Phone ____________________________

Components of Control



Very Poorly Controlled



≤2 d/week

>2 d/week

Throughout the day

Nighttime awakening

≤2 x/month



SABA for symptoms

≤2 d/week, not daily

>2 d/week

Several times/day

Interference with normal activity


Some limitation

Extremely limited

FEV1 or peak flow

>80% predicted/ personal best

60% – 80% predicted/ personal best

<60% predicted/ personal best

Validated Questionnaire














Exacerbations requiring oral systemic corticosteroids



Severity and interval since last exacerbation are recommended for additional refinement of risk estimation

Progressive lung function loss

Not Useful for isolated evaluation as in evaluation of LEOs

Treatment-related adverse effects

Covered separately in medications section