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U.S. Geological Survey Manual

SM 445-2-H CHAPTER 23

Occupational Medicine Medical Surveillance Program

Instruction:  Chapter 23 is revised to include medical screening and to specify preventative measures, such as vaccinations, for occupational exposures.   References were updated.  A major change to the chapter is requiring medical surveillance only when it is required by a standard or when an exposure assessment indicates exposures are unacceptable and unavoidable.  The information on bloodborne pathogens was removed since it is covered in Chapter 25.  The Job Hazard Analysis section was removed since it is covered in Chapter 15.  Appendixes were rewritten to clarify previous guidance.

1. Purpose.  The U. S. Geological Survey (USGS or Bureau) policy is to comply with medical surveillance regulations and provide appropriate immunizations and other medical services to prevent occupational illnesses.  This policy specifies the minimum program requirements for medical surveillance for personnel exposed to chemical, physical, and/or biological stressors such as noise, chemicals, biological contaminants, excessive temperatures, dusts, mists, and vapors.  This policy also specifies preventative measures, such as vaccinations that will be offered to personnel based on their jobs and/or exposures, and post-exposure evaluations that will be offered to personnel involved in an exposure incident. 

2.  Scope. 

A.  Medical surveillance will be provided to employees or volunteers who are or may be occupationally exposed to hazards that are covered by standards requiring medical surveillance or when occupational exposures exceed applicable Occupational Safety and Health Administration (OSHA) action levels or permissible exposure limits.  In this chapter, employees or volunteers are hereafter referred to as personnel. 

B.  Though not part of a medical surveillance program, clarification of criteria for preemployment medical evaluations for medical standards and physical requirements are included in this chapter.  These examinations are provided to determine if personnel and applicants meet established medical standards and physical qualifications for arduous or hazardous, i.e., physically or mentally demanding, job positions.  

C.  This chapter does not apply to drug screening and wellness programs.

3.  Authority/References.

A.  Executive Order 12196, Occupational Safety and Health Programs for Federal Employees; February 26, 1980.

B.  Title 29, Code of Federal Regulations, Parts 1910, 1915, 1917, 1918, and 1926.

C.  Department of the Interior (DOI) Manual, Part 485, Safety and Occupational Health Program, Chapter 17, Industrial Hygiene, and Chapter 18, Occupational Medicine Program.

D.  DOI Occupational Medicine Program Handbook, latest revision.

E.  OSHA Publication 3162, Screening and Surveillance: A Guide to OSHA Standards.

F.  Centers for Disease Control and Prevention Yellow Book, Health Information for International Travel, latest revision.

G. Advisory Committee on Immunization Practices, Recommended Adult Immunization Schedule (current year).

H.  Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities, National Institute for Occupational Safety and Health, Occupational Safety and Health Administration, U.S. Coast Guard, and Environmental Protection Agency; October 1985.

I.  Survey Manual 445-2-H, Occupational Safety and Health Program Requirements Handbook, Chapter 45, Heat Stress.

4.  Definitions.

A.  Action Level (AL).  Airborne exposure concentration which triggers compliance with parts of a standard.  This is often half of the permissible exposure limit (PEL) or threshold limit value (TLV).

B.  Biological Monitoring.  Periodic clinical laboratory tests, e.g., blood lead levels, serum creatinine levels, etc., used to detect the potential absorption of hazardous agents or potential physiological or pathological effects caused by hazardous agents.

C.  Excursion Limit.  An employer must ensure that personnel are not exposed to an airborne concentration of a contaminant in excess of the excursion limit.  This is often a 30-minute, time-weighted average.

D.  Exposure Assessment.  A process that identifies and characterizes occupational exposures to chemical, physical, and biological hazards.  The process normally involves a walkthrough of the worksite to characterize the task and identify exposures (an industrial hygiene survey) and measuring of personal exposure through air sampling (exposure monitoring).

E.  Exposure Monitoring.  A process that quantifies personnel exposures to physical, chemical, or biological hazards through air sampling techniques.  Monitoring results are compared with PELs or TLVs to determine exposure risk where appropriate.  Exposure monitoring should be performed by an industrial hygienist or other safety and health professional.  Also referred to as workplace exposure monitoring or personal exposure monitoring.

F.  Medical Clearance.  A medical evaluation that determines an employee’s ability to meet job-specific medical requirements to determine whether the individual can perform the job safely or safely wear personal protective equipment, e.g. ability to meet job specific physical requirements or ability to wear a respirator.

G.  Medical Screening.  A method for detecting disease or body dysfunction before an individual would normally seek medical care.  Medical screening includes biological monitoring and is usually administered to individuals without current symptoms but who may be at higher risk for certain adverse health outcomes due to potential workplace exposures. 

H.  Medical Standards and Physical Requirements.  Established medical and physical requirements for positions with duties that have been determined to be arduous or hazardous, i.e., physically and mentally demanding, and are considered essential for successful job performance. They are applicable to positions that, due to their physical and geographical location or the nature of the job, impose practical safety and health related requirements and restrictions on physical and health conditions of personnel.   Medical standards and physical requirements are governed by 5 CFR 339, Medical Qualification Determinations.

I.  Medical Surveillance.  The analysis of health information to look for problems that may be occurring in the workplace that require targeted prevention.  It is a mechanism to detect early or preclinical signs of adverse health conditions resulting from workplace exposures.  Surveillance may be based on a single case or sentinel event, but more typically uses medical screening and biological monitoring results from the group of employees being evaluated to look for abnormal trends in health status.  Surveillance can also be conducted on a single employee over time.  Review of group results helps to identify potential problems.  Medical surveillance is implemented based on the results of exposure assessments.

J.  Occupational Medicine Physician.  A doctor of medicine or doctor of osteopathy who passed the National Medical Board Examination or equivalent examination and has a license to practice within a given State(s).  In addition, the occupational medicine physician is certified to practice occupational medicine by the American Board of Preventive Medicine (ABPM) or is eligible for ABPM certification by completing specific education and practice in occupational medicine.

K.  Occupational Safety and Health Administration.  Department of Labor agency responsible for establishing and enforcing safety and health standards including permissible exposure limits and medical surveillance requirements.

L.  Other Qualified Occupational Health-Care Professional.  Physician’s assistants, registered nurses, and nurse practitioners who are licensed in a particular State and are certified in occupational medicine or occupational health nursing, or are eligible for certification through a combination of additional education and training in occupational health. 

M.  Permissible Exposure Limit.  An occupational exposure limit of a contaminant in the air to which nearly all workers may be repeatedly exposed during an 8-hour workday.  An employer must ensure that personnel are not exposed to an airborne concentration in excess of the permissible exposure limit.  This is often an 8-hour time weighted average, 15-minute short term exposure limit, or ceiling concentration.  PELs are established by OSHA and are regulatory requirements.

N.  Periodic examinations.  Conducted at predetermined intervals to evaluate and document the health impacts of occupational exposures.

O.  Personnel.  Any USGS employee or volunteer.  Students are classified as either employees or volunteers.

P.  Physical Examinations.  Determine fitness of an individual to perform work while evaluating evidence of acute and chronic injury and disease.  These examinations should be performed by the occupational medicine physician; however, other licensed health-care professionals such as a registered nurse or a physician's assistant may perform the examinations if supervised by the occupational medicine physician.

Q.  Regulated Areas.  Areas where entry and exit are restricted or controlled because of potential exposure to occupational or environmental hazards.

R.  Short-term Exposure Limit (STEL).  An employer must ensure that personnel are not exposed to an airborne concentration in excess of the short-term exposure limit.  This is usually a 15- minute, time-weighted average.

S.  Termination Examinations.

(1)  Termination of Employment Examinations.  Conducted when personnel leave employment in order to assess the relationship between future medical problems and prior exposures in the workplace.

(2)  Termination of Exposure Examinations.  Applicable when exposure to a specific hazard is removed.  Exposures to specific hazards may cease when an individual is reassigned, a process is changed, or the individual leaves employment.

T.  Threshold Limit Value (TLV).  Air contaminant exposure guidelines, developed by the American Conference of Governmental Industrial Hygienists, under which most people can work consistently for 8-hours a day with no harmful effects.  TLVs are listed as either 8-hour time-weighted averages or 15-minute short-term exposure limits.

U.  Time-weighted average (TWA).  Average concentrations over a period of time, usually 8 hours.

V.  Wet Bulb Globe Temperature (WBGT).  An index of the environmental heat that includes temperature, relative humidity, and radiant heat load based on an instrument that measures the air temperature using a dry bulb, a wet bulb, and a black globe thermometer.  The dry bulb plus the wet bulb temperature gives information about the relative humidity.  The black globe temperature gives information about radiate heat.  Using a standard formula, the WBGT is calculated.

W.  Workplace.  A physically definable area where work is performed.  Workplaces may be administrative, office, laboratory, field, or industrial, and are or may be staffed by personnel.

5.  General Requirements.

A.  Participation by personnel in the medical evaluations described in this chapter is mandatory when required by OSHA standards, Bureau or DOI policies, or when determined appropriate by an exposure assessment or other appropriate assessment protocol, e.g., risk assessment.

B.  Occupational medicine services, when required as a condition to perform work, shall be provided by management at no cost.

C.  Personnel under the age of 18 will not be permitted to perform activities requiring occupational medicine services as covered under this policy.

D.  Occupational medicine services will be performed by an occupational medicine physician or other qualified occupational health professional under the direction of an occupational medicine physician.  Where an occupational medicine physician or other qualified occupational health professional is not available, occupational medicine services may be provided by a licensed physician or licensed health-care professional, preferably one who has experience in occupational medicine, as described in the DOI Occupational Medicine Program Handbook, Tab 5.

E.  Medical examinations and clinical laboratory tests will be performed in accordance with the appropriate DOI or Bureau policy, OSHA standard, or in accordance with the professional judgment of occupational medicine physician if policies or standards are not available.  Refer to OSHA Publication 3162, Screening and Surveillance: A Guide to OSHA Standards, for minimum OSHA requirements for specific examinations and tests.  The DOI Occupational Medicine Program Handbook provides further guidance.   

F.  USGS headquarters and regional science centers or area offices shall designate the occupational medicine provider, but must allow personnel the opportunity to submit medical documentation from their personal physician, if they choose to use their personal physician.  In this case, a USGS-designated occupational medicine physician shall oversee the medical evaluations conducted by the personal physician, and review the examination results to ensure that the medical examinations and screenings administered conform to the established medical surveillance program protocols.

G.  Abnormal medical examination results will be communicated to management and the appropriate safety office for the purpose of investigating exposures and implementing corrective action.  Results shall be communicated in a format that adheres to Privacy Act and the Health Insurance Portability and Accountability Act requirements.

6.  Medical Surveillance.

A.  The purpose of medical surveillance is to look for abnormal trends in the health status of personnel exposed to chemical or physical hazards so that corrective action can be implemented to prevent or limit disease progression by controlling exposures or providing medical intervention.  Medical surveillance utilizes medical screening and physical examinations to detect abnormal biological effects before clinical symptoms appear. 

B.  Medical surveillance will be comprised of:

(1)  A baseline examination to be provided prior to assignment to a task for which medical surveillance is required, in order to document data that will be used to compare with future periodic examinations.

(2)  A periodic examination conducted at predetermined intervals to detect health effects from exposures.

(3)  A termination examination to be performed when exposure is removed and surveillance is no longer required.

C.  Inclusion into the medical surveillance program will be based on exposure assessment or exposure monitoring results and consultation with the industrial hygienist or occupational medicine physician.  Where exposures warrant medical surveillance, participation in the medical surveillance program is mandatory. 

D.  Exposures shall be eliminated or reduced to acceptable levels by engineering controls or work practices before medical surveillance is considered.  Where exposures cannot be reduced or it is not feasible to implement engineering controls or work practices to control exposures to acceptable levels, then medical surveillance is warranted. 

E.  Unacceptable exposures are occupational exposures to chemical or physical hazards above the AL, PEL, or TLV, as applicable.  See Appendix A, Table 2; Appendix B; and Appendix C for positions that may require a medical surveillance program.

F.  Personnel shall be included into a medical surveillance program when required by OSHA standards or Bureau policies, e.g., hazardous waste worker.

G.  Personnel who experience signs or symptoms of exposure to chemical or physical hazards will be medically evaluated and enrolled into the medical surveillance program as determined by the occupational medicine physician.

H.  Periodic medical evaluations generally are not recommended for exposure to biological hazards; however, it may be appropriate to offer targeted periodic evaluations to workers with substantial risk of exposure to infectious agents to detect preclinical or subclinical evidence for an occupationally acquired infection.  A risk assessment shall be conducted to assess exposure to infectious agents and to determine if periodic medical evaluations are warranted. 

I.  Personnel who experience signs or symptoms of exposure to a biological hazard will be evaluated as part of a post-exposure evaluation.  See paragraph 7.B below.

7.  Special Examinations.

A.  Immunizations.

(1)Personnel, who are potentially exposed to infectious diseases as a result of their work, will be offered the appropriate immunization, where available, prior to assignment of work or international travel.  Detailed recommendations for prevention of infectious diseases, including immunizations, are provided in Appendix D.

(2)  All personnel that work in the field and travel oversees will be offered a vaccination against tetanus and diphtheria and offered a booster vaccination at least every 10 years. 

(3)  Immunization for occupational exposure requirements shall be determined on a case-by-case basis in consultation with the occupational medicine physician or other licensed health-care provider.

 (4)  Preventative immunizations that are normally offered to the general public, such as influenza, may be provided as part of a science center’s wellness program.  

B.  Post-Exposure Evaluation

(1)  Post-exposure evaluations will be offered to personnel who were potentially exposed to an infectious agent during an exposure incident or who show signs or symptoms of exposure as a result of performing normal occupational duties.

(2)  Personnel who work in endemic areas or who handle potentially diseased wildlife or infectious agents may be offered a post-exposure evaluation when the individual is concerned about a potential exposure or infection.

(3)  Post-exposure evaluations will include a medical examination, prophylactic treatment, and/or a physician’s consult, as determined by the occupational medicine physician or licensed health-care provider. 

(4)  Personnel who are exposed to blood or other infectious materials from a human source shall follow the exposure incident protocol in USGS SM 445-2-H, Chapter 25, Human Bloodborne Pathogens Protection Program.

C.  Emergencies, Spills, Releases.  Some standards require a medical consultation in the event of a spill, leak, explosion, or other occurrence resulting in the likelihood of an exposure incident with a chemical or physical hazard, or when an individual develops signs or symptoms associated with a hazardous substance to which he or she may have been exposed during an incident.  Such medical consultations will be provided as needed.

8.  Termination Medical Evaluation.

A.  Termination of Employment Examination.  A termination examination will be performed whenever personnel enrolled in medical surveillance are transferred to another agency, are terminated, or retire.  This examination is conducted to identify medical conditions (or lack of) which are related to an occupational exposure.

B.  Termination of Exposure Examinations.  This examination will be conducted when personnel are being removed from a medical surveillance program because the individual is no longer exposed to the particular hazard in the workplace.  Exposures to specific hazards may cease when personnel are reassigned or when a process is changed.

9.  Medical Evaluations for Established Medical Standards and Physical Requirements.

A.  Preemployment medical evaluations for medical standards and physical requirements are governed by 5 CFR 339 (Medical Qualifications).  Establishing medical standards require an evaluation by a team of subject matter experts from DOI and the Bureau and must be established in accordance with Office of Personnel Management (OPM) procedures.  The USGS may establish physical requirements for individual positions when such requirements are considered essential for successful job performance.  The physical requirements of a position are determined by management.  Physical requirements shall be established in accordance with the Bureau’s Human Resources policies for developing physical requirements.

B.  Preemployment and periodic medical evaluations for certain job positions may be required by DOI policies or Federal regulations.  See Appendix A, Table 1, for a list of current positions within the DOI that require preemployment and periodic medical evaluations.  Where DOI policies or Federal regulations do not exist, the USGS may establish medical evaluations for specific positions with medical standards or physical requirements to ascertain whether an individual has any health conditions that may prevent him or her from safely and efficiently performing the essential functions of the position in which they have been selected.  The need for a medical evaluation must be clearly supported by the nature of the work, and personnel must be notified in writing of the reason their position requires medical evaluations. 

C.  Medical Determinations and Recommendations.  The role of occupational medicine personnel in addressing employment decisions is limited to determining whether the individual meets the medical requirements of the position and can, from a medical standpoint, perform the job capably and safely.  A medical examination alone cannot determine an individual's ability to perform the essential duties of a particular position.  The responsibility for making this determination rests solely with the selecting supervisor.  Employment-related decisions involving health are fundamentally managerial, not medical.  However, medical information may be an essential element in determining an individual's suitability for job tasks.  Management has the obligation to consider issues that are not strictly medical, e.g., reasonable accommodation or assessment of undue hardship on the agency's operations.

10.  Recordkeeping.

A.  Medical records shall be filed in accordance with the Bureau’s policy governing the Employee Medical File System (EMFS).

B.  The Bureau’s policy governing the EMFS shall be in accordance with current OSHA regulations, the Health Insurance Portability and Accountability Act, the Privacy Act, and 5 CFR 293.503.  Current guidance on maintenance of medical record can be found in the DOI Occupational Medicine Program Handbook.

C.  Medical records shall be maintained separately from other personnel records.  (NOTE:  See SM Chapter 432-1-S1, General Records Disposition Schedule, for medical records retention/disposition schedules.)

D.  Personnel have the right to access their medical records in accordance with 29 CFR 1910.1020 and shall be provided access to their medical records in accordance with the Bureau’s EMFS instructions.

E.  When personnel use their personal physician to administer occupational medicine evaluations as part of the requirements of the job position, the medical information, including medical monitoring and medical screening results, shall be submitted to the USGS or designated representative in accordance with OPM instructions and maintained in accordance with the Bureau’s policy governing the EMFS.

11.  Responsibilities.

A.  Bureau Occupational Safety and Health Program Manager and Bureau Industrial Hygienist.

(1)  Oversee the Bureau’s medical surveillance program and reviews and updates this policy, as needed.

(2)  Evaluate regional and headquarters medical surveillance programs during on-site visits.

(3)  Assist Regional Safety and Health Program Managers in establishing medical surveillance contracts.

(4)  Provide technical guidance to area safety officers, collateral duty safety program coordinators, and management on medical surveillance issues.

(5)  Oversee the exposure assessment process throughout the Bureau.

B.  Regional Safety and Health Program Managers.

(1)  Provide oversight of the medical surveillance program within their region through the Chief, Office of Regional Services.

(2)  Assist Area Safety Officers in identifying and quantifying chemical, physical, and biological workplace exposures.

(3)  Ensure workplace exposures are characterized by industrial hygiene surveys and exposure monitoring, i.e., exposure assessments.

(4)  Review regional industrial hygiene surveys and exposure monitoring data to ensure appropriate personnel are included in the occupational medicine program.

(5)  Provide recommendations on how to eliminate or minimize occupational exposures.

(6)  Assist Area Safety Officers in implementing the medical surveillance program and establishing medical surveillance contracts.

C.  Area Safety Officers.

(1)  Provide oversight for the medical surveillance program in their area of responsibility.

(2)  Assist Collateral Duty Safety Program Coordinators (CDSPCs) in identifying and quantifying chemical, physical, and biological exposures during on-site reviews and provide recommendations to eliminate or minimize occupational exposures.

(3)  Coordinate exposure assessment results and analyzes exposure monitoring data to ensure abatement is conducted as necessary.

(4)  Assist regional field location CDSPCs in establishing local medical surveillance contracts and developing occupational medicine programs.

(5)  Provide up-to-date guidance to human resources staff and supervisors on medical surveillance requirements based on Bureau and OSHA requirements.

(6)  Conduct surveys and investigations when medical surveillance results identify abnormal conditions related to occupational exposures.

D.  Collateral Duty Safety Program Coordinators.

(1)  Provide technical assistance to project leaders in implementing this policy.

(2)  Provide guidance to supervisors and project chiefs in finding a physician or other licensed health-care professional, preferably an occupational medicine physician.

(3)  Assist supervisors and project chiefs in identifying personnel who require medical surveillance based on exposure assessment results.

(4)  Work with supervisors and project chiefs to ensure records of exposure monitoring data are included in the personnel medical folder (SF 66D). 

(5)  Work with supervisors and project chiefs to implement engineering or administrative controls to reduce or eliminate unacceptable occupational exposures to chemical, physical, or biological hazards.

(6)  Work with supervisors and project chiefs to acquire personal protective equipment (PPE) and train personnel in the proper use of PPE when engineering or administrative controls are in the process of being implemented, are not feasible, or are not effective in protecting personnel from occupational exposures to chemical, physical, or biological hazards.

E.  Organizational Managers and Supervisors/Project Chiefs/Laboratory Supervisors.

(1)  Utilize engineering controls and work practices to eliminate or reduce exposures to acceptable levels where feasible, and utilize respiratory protection where exposures cannot be controlled to acceptable levels.

(2)  Identify personnel who require medical surveillance, immunizations, and medical clearance examinations.

(3)  With guidance from the Bureau or respective Regional Safety Office, develop and fund, as necessary, a medical surveillance contract with a health-care provider, e.g., U.S. Public Health Service or private occupational health clinic.  See Section 12 below.

(4)  Utilize an occupational medicine physician or other occupational health practitioner to administer medical examinations and to review medical examination results.

(5)  Notify safety and health staff and Human Resources of new hires, terminations, or job reassignments to ensure that personnel receive the appropriate preemployment and termination examinations.

(6)  Schedule and coordinate medical evaluations for applicants and employees to include pre-employment, baseline, periodic, and termination medical examinations, as appropriate.  When leaving the Bureau, termination examinations shall be documented on the individual’s exit clearance Form 9-090.

(7)  Provide necessary information to the examining physician.  Examples of information to be provided by the supervisor to the physician or other licensed health-care professional are provided in the following list.  Specific requirements are described in each appropriate standard.

(a)  A copy of the appropriate standard(s) and its appendixes.

(b)  A description of the duties of the affected personnel as they relate to exposure.

(c)  The representative exposure level.

(d)  The anticipated or estimated exposure level (for baseline and periodic examinations or in cases of exposure due to an emergency).

(e)  A description of any personal protective equipment used or to be used.

(f)  Information from previous medical examinations of the affected personnel which is not otherwise available to the physician or other licensed health-care professional performing the examination.

 (8) Maintain local contracts or memorandums of agreement for medical surveillance and other occupational medicine services.  (NOTE: Where more than one science center or area office is supported by an occupational medicine services provider, they may implement an agreement defining which office has responsibility for maintaining the medical surveillance contract, e.g., Human Resources.)

(9)  Document position criteria requiring medical surveillance in position descriptions and ensure criteria are included in recruitment and termination paper work. 

(10)  Provide recruitment paperwork to Human Resources with medical surveillance requirements in order to provide baseline examinations for applicants hired into positions.

F.  Personnel.

(1)  Participate in the Bureau’s medical surveillance program when required by Bureau or Federal policies.

(2)  Complete required forms and provide appropriate medical history to medical personnel performing the examination.

G.  Human Resources.

(1)  Ensures that applicants receive baseline medical examinations when required for job positions with medical surveillance requirements by notifying the hiring cost center that a baseline and other preemployment examinations are required prior to appointment of the applicant.

(2)  Oversees the Bureau’s EMFS and develops written internal implementing instructions, in accordance with 5 CFR 293.503, describing the overall operation of the Bureau’s EMFS to include who is responsible for the overall management of the system; describing under whose custody employee medical records will be physically maintained; and the process for proper retention, security, disclosure, and access of medical records.   

(3)  Upon initial employment and annually thereafter, informs personnel or ensures that personnel are informed of their right to access their exposure and medical records, in accordance with 29 CFR 1910.1020, and provides them access to their medical records in accordance with the Bureau’s EMFS instructions.

H.  Contracts for Occupational Medicine Services.  When contracting services for medical surveillance, ensure that contractor responsibilities include, at a minimum, provisions for the following:

(1)  Inform personnel receiving occupational medical examinations of any specific health risks that can result from their particular occupational exposures. 

(2)  Provide counseling concerning the methods to protect against particular occupational exposures.

(3)  Provide a copy of the medical examination results to personnel and explain the implications of any abnormal results.

(4)  Provide a written medical opinion to management and safety and health personnel concerning negative medical evaluation results for use in investigating negative health outcomes related to occupational exposure.

(5)  Will not provide any medical information to management except the written medical opinion.

(6)  Obtain a written release from personnel so that specific safety and health results can be released to the safety and health personnel responsible for investigating negative health outcomes related to occupational exposure.

(7)  Maintain medical records in accordance with privacy laws.

 

/s/ Karen D. Baker                                                                        April 22, 2010
_____________________________________               ____________                      
Karen D. Baker                                                                             Date
Associate Director for Administrative Policy and Services

Appendices
Appendix A
Appendix B
Appendix C
Appendix D

 


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