Part 1, Chapter 9: Manual Appendix 1-9-F

These instructions apply to employees at all Indian Health Service facilities.

For the purposes of this exhibit, the following definitions are added to those already contained in Chapter 9.

1. Employee Medical File System (EMFS).  Agency's complete system composed of control procedures; implementing instructions; all automated, microfilm, and paper records on employee illnesses, accidents, injuries, and exposures; and other medical or health maintenance matters.
2. EMFS Manager.  Agency-wide official who is assigned responsibility for management of the agency-wide EMFS.  This may be a medical or allied health professional.
3. Employee Medical File (EMF).  A separate file folder (Standard Form 66-D or approved equivalent) that contains all relevant medical records designated for long-term retention, which accompanies the employee during his or her Federal career and is stored with the Official Personnel Folder/Merged Personnel Record Folder (referred to as the OPF) at the National Personnel Records Center (NPRC) after the employee's termination or retirement.
4. Epidemiological Record.  Contains statistical patient health and environmental sampling data, assembled and analyzed to enable conclusions to be drawn regarding occupational exposure of groups of workers.  No personal identifiers are included in this composite data.
5. Exposure Record.  An individually identifiable record of radiation exposure or of exposure to an environmental health hazard, toxic substance, or harmful physical or biologic agent (as defined in OSHA documents, 29 CFR 1910.20 (c)(6) and (11)).
6. Implementing Instructions.  Refers to any form of internal Agency issuance that provides the guidance required by 5 CFR 293.503 and as described below in this exhibit.
7. Non-occupational Patient Record.  Refers to a record of medical treatment of examination, either inpatient or outpatient, maintained by a health care facility, which may for completeness or health maintenance of the employee be included in the EMF, e.g., records of voluntary employee physical exams, administration of allergy shots, or records of non work-related medical treatment or examination.
8. Non-personal Record.  Any Agency aggregate or statistical data resulting from studies covering groups of employees or resulting from studies of the worksite environment, e.g., data on employee accidents, health profiles, or exposure incidents.

   NOTE:  This record should not include any patient identifiers if it is to be reviewed outside of the occupational safety and health department.

9. Occupational Illness/Accident/Injury Record.  Certain forms (eg., CA-20 or Agency developed form) that record an on-the-job occupational 'illness, accident, or injury if medically related will be filed in the EMF.  When a claim is filed with the Office of Workers Compensation Programs (OWCP) the case papers physically retained at OWCP are not part of the EMFS, but any Agency retained file related to the Federal Employee Compensation Act (FECA) claim is considered as part of the employee's EMFS records.
10. Occupational Medical and Related Record.  A chronological, cumulative record, regardless of the form or process by which it is maintained (e.g., paper document, microfiche, etc.), of information about health status developed on an employee and related to employment, including personal and occupational health histories, exposure records, medical surveillance records, and records about occupational illnesses and diseases.  Related records include the opinions and written evaluations generated in the course of diagnosis and/or treatment by medical health care professionals and technicians or by industrial hygienists.  For the purposes of this chapter supplement, the term "medical record" is deemed to mean treatment, exam, exposure, and occupational medical and related records when they are properly filed in the EMFS/EMF.
11. Occupational Safety and Health (OSH) and Office of Workers' Compensation Programs (OWCP) Long-term Record.  Those medical records defined in OSHA regulations (29 CFR 1910 and 1960) and designated for retention for the duration of employment plus 30 years and reports of occupational illness, accident, or exposure and related records, required to be completed under Agency or OWCP regulations (20 CFR 10), whether or not a FECA file is created.

Internal Agency instructions on maintenance of the EMFS must be prepared with joint participation of IHS medical, health, safety, and personnel officers and should be reviewed by Privacy Act staff.  Consultation with Agency labor organizations must be afforded.  The following instructions are suggested for standardization of the EMFS.

1. Overall Operation.  The medical records designated as part of the EMFS must be in a secure location identified to the EMFS manager and IHS Headquarters OSH staff.  They are to be retrieved for inclusion of health or environmental data entry, and may require duplication of some documentation from the worker's general medical record in order to include information essential or useful for the employee's health and for OSH surveillance.
2. Location.  A description of where and under whose custody employee medical records will be physically maintained (e.g., in a section of the general medical records file room, dispensary, or personnel office; in custody of the EMFS manager or other responsible individuals) should also be provided in writing to the EMFS manager.
3. General Guidance.  The EMFS must be maintained in accordance with established retention schedules, and procedures to establish an EMF for an active employee must at a minimum include initiation of a file at the time of a first visit following issuance of this manual.  For the majority of health care facility workers, this should require no more than 12 months, in the context of the currently required annual tuberculosis skin testing policy.  When an employee transfers to another facility or agency, or leaves Federal service, the EMF may follow to the next agency with a move, retirement, or resignation.  If there is no gaining agency, the EMF shall be transferred along with the employee's personnel file to the National Personnel Records Center (NPRC) or a regional Federal Records Center.
   1. Disclosures.

      Disclosures of EMFS records, both to individuals outside the IHS and to IHS officials, are restricted in order to protect personal privacy, particularly with regard to records of physician treatment or examination.  These records generally should not be made available to non-medical personnel versus those medical reports that are properly provided to management for the purposes of making decisions affecting the employee.  The confidentiality of the doctor-patient relationship is protected by the IHS Privacy Act.  Routine use of the records, retention and disposal of the record, accessing of the record, and restricted accessing of the record by current and former employees and other requesters; and amendments of the records are described in the EMFS system notice of the Office of Personnel Management, OPM/GOVT-10.  Of note, routine uses of a record are permissive in nature, and the EMFS custodian is not required to make a disclosure or release the full record.  If the custodians of the record have concerns about making a disclosure, they should consult with the EMFS manager, the IHS General Counsel, or other IHS responsible official.

   2. Confidentiality.

      The first responsibility of the IHS is to protect the confidentiality of the records whenever possible.  The mere receipt of a request for a record under one of the established routine uses is not, ordinarily, sufficient to warrant the release of all records on the employee.  Scope of the request should be carefully examined and narrowed whenever feasible.  Only the specific record sought or a portion of that record should be released, and, if appropriate, a report by competent IHS officials on the contents of the file should be furnished in lieu of the record itself.  All routine disclosures should be recorded and retained for five years or the life of the record, whichever is longer.

   3. Retention Schedule.

      The retention schedule herein has been established by the NARA and is binding on Federal agencies.  The IHS Records Management Officer should be consulted with any questions.  Disposal of records shall be by shredding, burning, or erasure of disks or tapes.

      Temporary medical records may be maintained as part of the EMFS, covered by the procedures of this chapter exhibit and covered by the Office of Personnel Management's EMFS Privacy Act system notice.  However, they are not to be placed in the EMF being sent when the employee transfers to another agency or when the EMF is sent to the NPRC.  Temporary medical records most commonly refers to Drug Testing Records in other federal agencies; there is no Drug Testing Program of employees in the Indian Health Service, but this paragraph is included for completeness.

      Medical records considered to be long-term records in the EMFS must be maintained for the duration of employment, plus 30 years.  Therefore, upon separation from the employing Agency, the records either accompany the employee to a new assignment or are transferred to NPRC for disposal in accordance with the GRS #1.

   4. Current Employee Access to Records.

      All Federal agencies are required by Privacy Act regulations to make the initial decision on a current employee's request for access to his or her EMF.  The IHS may establish any internal procedures that it chooses for processing such requests without imposing any condition beyond those contained in the regulations or guidance of the Office of Personnel Management (OPM).  Furthermore, special accessing permitted by the Privacy Act for a physician or other person to receive the record, should only be made by the IHS EMFS manager or designated medical officer.  If IHS withholds any records, the requester must be informed of his/her right to appeal the IHS decision in writing to the Office's Assistant Director for Workforce Information, 1900 E Street, NW, Washington, D.C. 20415.

   5. Requests For Access to EMFS Records By Former Employees.

      If IHS receives a request for access to EMFS records by a former employee, it must determine if the Agency still has any EMFS records, (e.g., temporary records not sent with the EMF, or the EMF itself).  For any records still retained, the request will be processed the same as a request from a current employee.  If IHS has retained temporary records after having sent the EMF to the next agency or to the NPRC, and those temporary records are still covered by the OPM Privacy Act for EMF system of records (i.e., still within the retention schedule), then the Agency will provide access.  If the temporary records have been retained beyond the established retention schedule, since they are no longer covered by the OPM system of records, the Agency is responsible for issuing both the initial decision and for processing any appeal of a denial.  A request for access to an EMF when the EMF has been sent to another employing agency will require the request to be referred to that agency.  If the EMF has been sent to the NPRC, the request will be referred to the Office's St.  Louis Office, OPM/EMF Access Unit, for appropriate action.

   6. Amendment Requests.

      As in the case of an access request, under the Office's Privacy Act regulations an agency makes the initial determination when a current employee requests amendment of an EMFS record (temporary or long-term).  Any agency denial requires that the IHS inform the requester of his or her right to appeal the decision to the Office's Assistant Director of Workforce Information.  Amendment requests from former employees for long-term EMF records also will be referred to this office.

   7. Exempt Records.

      Traditionally, an individual has had the right to access his or her medical records.  Therefore, the Office has claimed no Privacy Act exemptions for records in the EMFS/EMF.  Additionally, when an individual cannot name a physician to receive the records (e.g., because of economic or religious reasons), the IHS should consider giving the records to an alternative responsible person named by the individual, e.g., a spouse, parent, or clergy member.

   8. Method of providing access to EMFS records

      The IHS must provide the requester with either a copy (at no cost) of the record, or the right to personally review his/her own total EMFS/EMF contents.  Any written designation of access of an employee's record must include the specific identity of the representative and of the records to be provided.

1. Establishment.

   When initially implementing the EMFS, IHS facilities need to establish an EMF only when there are medical records that are appropriate for filing in an EMF and only when the employee leaves the employing agency.  At a facility's discretion, an EMF may be established when an employee moves within the employing facility, e.g., when the IHS decides to transfer that employee's medical records to a new servicing location.  The IHS is authorized by OPM to require the establishment of an EMF when medical records exist for its current employees (or all new hires).

2. Reviewing an EMF of a former Federal employee.
   1. When the EMF is located in the NPRC, an agency may request the former employee's EMF with that individual's OPF only when the requesting agency has specific authority to do so, e.g, when determining if the applicant can meet specific medical standards identified for the position before being appointed.  When there are no specific medical standards and the agency does not have the authority to require all applicants to undergo a physical examination prior to appointment, the agency must make its decision without reviewing the EMF.  The IHS may not request the NPRC to forward the EMF to the IHS EMFS manager until an employee has been employed 30 days.  This delay is designed to prevent unnecessary retrieval of an EMF, with the attendant potential for inappropriate or unnecessary disclosure of highly sensitive data.
   2. When the EMF is located with a former employing agency, the need for the record from the most recent non-Federal employer should be clear before a request is sent to the last employing agency.  The retrieved and transferred records should be placed into an EMF and forwarded to the EMFS manager designated by the requesting agency.  Thereafter, the receiving agency will be responsible for maintaining both the records it received and any it may create for the employee.
3. Reviewing the EMF of a current Federal employee.

   When an agency is considering an employee of another agency for possible selection, it may review that employee's EMFS records only under the conditions described in paragraph B(1) of this section.  In these cases, the reviewing agency may wish to consider a written stipulation from the employing agency's EMFS manager that specific qualifications for the position can be met by the candidate.  In all other cases, a general statement by the employing agency that there is no evidence of a health condition that would prevent the candidate from performing the duties of the position should suffice.

4. Reviewing an EMF for other than employment reasons.

   If it becomes necessary (e.g., in matters before a judicial or quasi-judicial authority or for other legitimate agency reasons), an agency may retrieve an EMF from the NPRC or another agency.  The request to NPRC will be made in accordance with any instructions issued by NARA.

   Content of the Employee Medical File:

   1. Applicant Medical Records.
      
      

      Medical records pertaining to an applicant, including Drug Testing Records under Executive Order 12564, are part of the OPM/GOVT-5.  Recruiting, Examining, and Placement system of records are not part of the EMFS.  Only when an applicant is subsequently hired will those medical records created during the application for employment process be retained in the IHS-generated EMFS, and shall include:

      1. Forms, e.g., Standard Forms 88 and 93, Medical History and Physical Examination, submitted with job application or completed shortly after entrance on duty.
      2. Records created/submitted when demonstrating that the applicant qualifies for appointment under special authorities regarding employment of the severely physically or mentally disabled.
      3. Records that demonstrate that the applicant meets the medical standards identified in the Office's X-118 and X-118C handbooks.
   2. Medical records created during employment.

      Records created as a result of a condition of employment or as a result of an on-the-job occurrence.

      1. Those resulting as a condition of employment include:
         1. Records necessary to demonstrate that the employee continues to meet the medical standards for the position, e.g., periodic hearing, sight, or physical examinations.
         2. Records to support placement of the employee in a light duty status or which lead to some other temporary accommodation made by an agency, e.g., a detail because of a medical condition.
         3. Records created under the agency's employee health monitoring programs.
      2. Those arising as a result of an on-the-job occurrence are of two kinds.

         Exposure records that include:

         1. Employee health surveillance records (e.g., regularly scheduled employee examinations, including audiograms, blood tests, and periodic readings of employee monitoring meters or badges).
         2. Records from emergency situations (e.g., toxic agent exposure requiring immediate examination).
         3. Industrial hygiene records documentation of exposure levels, including: physical, biological, chemical, and radiological workplace hazards.
      3. Occupational illness or injury records, regardless of whether the person files a claim for compensation with the Office of Workers' Compensation Program (OWCP).
         1. When no compensation claim is filed, a record of the occupational illness or injury should be made part of that employee's EMF record, along with any record of treatment by agency staff or furnished by the employee's private physician.
         2. When a claim is filed with OWCP, the official copy of the claim file is maintained by OWCP, but the IHS maintains a duplicate claim file (FECA file) during the processing of the case and during the period that benefits are being received.  The duplicate file may be retained at the service unit where the employee works, and at the Area or Headquarters facility where processing has been taking place.  It is recommended that since the agency policy is to retain the agency FECA file for the duration of compensation, that the EMF also be retained. A notation is to be made in the employee's OPF that the EMF is being retained by the last employing agency.  When compensation ceases and the FECA file and other EMF records are still subject to the 30-year retention schedule, a notation will be added to the EMF to indicate that the individual is off compensation and, if known, state whether the person is or is not capable of working.  The EMF will then be sent to the NPRC for storage.  If the FECA file and other EMF records are 30 or more years old, then the retention schedule for EMFS records has been met and the records may be disposed of in accordance with the agency's internal records schedule for EMFS records.
5. Records created during the separation process.

   Such records include termination medical examinations for those employees working in areas with hazardous materials as a documentation of medical status at the time of discharge.  Records shall also be created for an agency-initiated separation, for an agency or employee initiated application for disability retirement, and when the employee dies in service.  Records involved in a granted disability retirement or in a death would be those that are:

   1. Relied upon in reaching a decision for the IHS to initiate a request for disability retirement.
   2. Provided by the employee in connection with an application for disability retirement.
   3. Resulting when the employee dies in service.

   NOTE:  Although the OPM will retain copies of medical records received in connection with a disability retirement issue (whether or not it is granted) and in death-in-service situations, the IHS should also place copies of these records in the subject's EMF.

Records that are generally not considered part of the EMFS but may become part under certain conditions include:

1. Employee assistance/counseling records.

   These records relate to counseling on personal or on drug/alcohol abuse problems, when the employee formally enters into such a program.  While such EAP files might include copies of medical records from the EMFS/EMF, inclusion of any counseling-related records in the EMFS or the EMF is not allowed due to the confidentiality mandates of the statutes establishing such programs.  When the employee voluntarily seeks and accepts counseling or, upon the recommendation of management, enters into the IHS' counseling program, then he or she is considered to be formally entered into such a program.  Otherwise, medical records released to these problem areas are considered to be part of the EMFS.  Formal counseling records may be included in the EMFS only when the employee consents.

2. Non-occupational Medical Patient records.

   Such records can include those the IHS maintains or those maintained by a non-Federal treating physician, hospital (inpatient or outpatient), or health care facility (e.g., DOD or VA hospital or clinic).  When the treatment or examination received by the employee is directly related to the position held (e.g., where regularly recurring physical examinations or examinations are part of the conditions for continued employment), is the result of an occupational illness or injury, is due to an exposure incident on the job, or is performed as a result of an IHS employee health monitoring program, then a copy of the record of treatment/examination should be made part of the EMFS/EMF at the time treatment/examination occurs.

3. The following records may be placed in an individual's EMF only when it is clear that the report covers a situation in which that employee was involved.
   1. Non-personal records.  These are records about working conditions or the work environment that contain no specific information about individual employees but were prepared from information about other unspecified employees.  For example, a notation could be entered into an employee's EMF regarding an indication for increased surveillance or special testing of this employee, such as uncertain recent work exposure to patients diagnosed with infectious tuberculosis or other dangerous communicable disease, after the diagnosis of occupational illness or injury in a coworker.  This notation could be made either for a planned intervention involving the employee, or merely to evaluate need for intervention via an investigation-generated report.  After the report is prepared the individual record may be destroyed or filed in another system.
   2. Records on working conditions.  Such records would be those that provide data about the work environment, e.g., quality of air, hazardous agents (chemical, physical, biological) in the work environment, or protective equipment utilizations and training.

1. Classified Records.  Such a record carries a defense classification, and would be declassified prior to transfer to an IHS EMFS.
2. X-Ray Records.  Some X-ray records will fit within the EMF while others do not, e.g., the Chest/Torso X-ray.  The NPRC cannot accept an EMF with documents extending beyond the border of the folder nor will it accept boxed oversized X- rays.  These X-rays, in cases where OSHA standards apply, must be retained at the service unit where originally interpreted for the duration of employment plus 30 years.

NOTE:  Asbestos surveillance X-rays must be retained for the duration of employment plus 30 years.  Most other X-rays, e.g., arm or leg, are usually recorded on film that fits within the border of the EMF and should be included in the EMF.  When the oversized X-ray is required to be retained, the creating agency must retain it and include a notice in the EMF as to how a subsequent custodian of the EMF may obtain it.  Should technology permit, and the OSHA standards allow, a microfiche copy of any X-ray may be placed in the EMF in lieu of the X-ray itself.

1. The physical location for retention of EMFS records or active EMFs is an IHS prerogative.  Facilities should retain such sensitive data in a physically secure location apart from the main body of patient medical record; that is, the EMFs of a service unit or facility should be kept together in one cabinet or group of cabinets to ensure the integrity, privacy, and availability of the records for clinical use and regulatory and surveillance functions.  Alternative sites include the location where employees receive occupational health clinical services (either on- or off-site), or office of the local EMFS manager, provided that the location is at least as secure as the general medical records department.
2. EMFS records should not be located in the same office with the OPF, in order to avoid inappropriate disclosure of the records.  Only staff with essential occupational health duties are authorized to use the EMFS or any individual EMFs.  Medical records that had been stored in an OPF prior to the advent of the EMFS should be removed from the OPF and placed in the EMF at the time of its activation.

The EMF of each employee who is in a position subject to civil service rules and regulations is part of the records of the OPM, entrusted to the IHS.  When the EMF also contains medical records created during employment in a position not subject to the IHS or OPM's civil service regulations, e.g., with the Postal Service, the EMF is then part of the records of both the OPM and the non-civil service employer.

1. When retiring an EMF to the NPRC, the IHS must use the folder prescribed by the OPM and available through the Federal Supply Service.  This blue folder is identified as Standard Form 66-D, Employee Medical Folder.  This is the only folder that will be accepted by the NPRC for storage of medical records.
2. When IHS establishes an EMF on a current employee, it will be used to transfer medical records when necessary within the IHS, e.g., when an employee transfers to another service unit.  When an EMF is not used for current employees, any folder or a sealed envelope may be used to retain or transfer the record.  However, when transferring records to another agency, the prescribed EMF must be used.
3. When the medical records of an employee fall under the jurisdiction of two agencies, e.g., the IHS and the US Postal Service, the prescribed EMF is to be used.

It is the obligation of the gaining/appointing agency to locate and obtain any prior medical records for the new employee, either from the last employing agency or from the NPRC.

(Exception: any new employee who left his or her last agency on or prior to September 1, 1984.)  Medical records for an employee transferring into an agency should be in the SF 66-D, and IHS should continue to use it for storing any medical records created on the individual.  If the medical records are not in the SF 66-D (e.g., in an envelope or other folder that has been identified as the EMF) the gaining agency should transfer those records to the SF 66-D.

Over the years, agencies have stored medical records of separated employees in different locations; therefore, the procedures for obtaining medical records vary according to when and where they were stored.  Before 1978, medical records were sent to the National Personnel Records Center.  Between 1978 and August 1984, they were sent to either the NPRC or to one of the regional Federal Records Centers.  In addition, some medical records (e.g., SF 88, SF 177, and CA-1 and CA-20 forms) were filed (either interfiled or included in a separate envelope or agency-designated folder) in OPFs that were sent to the NPRC.  Since August 1984, agencies have been required to consolidate the medical records of each separated employee in an EMF, SF 66-D, and to send the EMF to the gaining Federal agency.