1 U.S. DEPARTMENT OF HEALTH COMMISSIONED CORPS

U.S. DEPARTMENT OF HEALTH COMMISSIONED CORPS INSTRUCTION

AND HUMAN SERVICES

CCI 221.02

EFFECTIVE DATE: 12 June 2019

By Order of the Assistant Secretary for Health:

ADM Brett P. Giroir, M.D.

SUBJECT: Medical Readiness

1. PURPOSE: This Instruction states the medical readiness requirements for officers in the

Commissioned Corps of the U.S. Public Health Service (Corps) and candidates for a commission

in the Corps (hereinafter referred to as “applicants”). It provides policy on the completion, review,

and disposition of the medical reports.

2. APPLICABILITY: This Instruction applies to all Corps officers and applicants. It is not applicable

to disability separation/retirement medical examinations (see CCI 393.01, “Medical Review

Board”).

3. AUTHORITY:

3-1. 42 U.S.C. §204a, “Deployment readiness”

3-2. 42 C.F.R. §21.24, “Physical examinations”

3-3. 42 C.F.R. §21.34, “Certification by candidate; requirement of new physical examination”

3-4. Commissioned Corps Directive (CCD) CCD 128.01, “Medical Fitness for Duty”

3-5. CCD 111.03, “Conditions of Service”

4. PROPONENT: The proponent of this Instruction is the Assistant Secretary for Health (ASH). The

responsibility for ensuring the day-to-day management of the Corps belongs to the Surgeon

General (SG).

5. SUMMARY OF REVISIONS AND UPDATES: This is the first issuance of this Instruction in the

electronic Commissioned Corps Issuance System (eCCIS) and replaces Commissioned Corps

Personnel Manual (CCPM) CC29.3.5, “Medical Examination Requirements,” dated

24 October 1997. This version:

5-1. Clarifies the medical requirements for candidates seeking a commission in the Regular

Corps and Ready Reserve Corps.

CCI 221.02 Medical Readiness 12 June 2019

5-2. Establishes that candidates may obtain medical examinations through the Department of

Defense Medical Exam Testing System (DODMETS) under the direction of the Department

of Defense Medical Examinations Review Board (DODMERB).

5-3. Authorizes the SG to grant a medical waiver to a candidate who has a disqualifying medical

condition.

5-4. Specifies that a candidate must notify Medical Affairs of any change in his/her health status

occurring after submission of any medical information and before being called to active

duty. It also specifies the consequences of failing to disclose any medical information

and/or failure to adhere to the requirements of this Instruction.

5-5. Clarifies the Latent Tuberculosis Infection (LTBI) testing requirements for applicants.

5-6. Authorizes the SG to establish the specific requirements of the medical examinations for

applicants and officers.

5-7. Replaces the 5 year physical evaluation for active duty officers with the periodic health

update, and incorporates substance use and mental health screenings.

5-8. Incorporates Section 5.a. of Manual Circular (MC) 377, “Basic Level of Force Readiness

Standards for the Commissioned Corps of the U.S. Public Health Service (Corps),”

dated 4 June 2014, regarding the immunization requirements and clarifies the LTBI testing

requirements for officers. It also provides additional guidance on the annual influenza

immunization.

5-9. Incorporates Section 6 of MC 377 regarding medical waivers and clarifies when the Corps

will grant a medical waiver to an officer.

CCI 221.02 Medical Readiness 12 June 2019

6. POLICY:

6-1 General.

a. For the purposes of this Instruction the word “medical” used in the context of

examination, fitness, or readiness refers to physical, dental, and mental health.

b. Active duty Corps officers must be able to perform the duties defined in

CCD 111.03, “Conditions of Service,” Section 6-2. To determine an officer’s

medical readiness, all officers must undergo periodic health evaluations and must

maintain the required immunizations.

6-2. Physical Examinations.

a. Applicants to the Regular Corps. Examinations of applicants are used to determine

medical qualification for an appointment into the Corps and for baseline

documentation of abnormalities existing prior to call to active duty. Therefore, it is

necessary that every finding of a variance from normal be reported.

(1) The medical examination is usually obtained through the Department of

Defense Medical Exam Testing System (DODMETS) under the direction of

the Department of Defense Medical Examinations Review

Board (DODMERB). A dental examination and some laboratory tests are

also required of all applicants. The scheduling and payment of the dental

and laboratory examinations are the responsibility of the applicant.

Applicants are also financially responsible for any necessary supplemental

evaluations. Some applicants may be required to get their physical

examinations outside of the DODMERB process. In these cases, the

applicant will be financially responsible for all components of the health

evaluation. The SG will determine the basic evaluation and testing

requirements for applicants (see POM 821.71, “Physical Examination

Requirements”).

(2) DODMERB and Medical Affairs (MA) within the Commissioned Corps

Headquarters (CCHQ) will utilize the guidance in the most current version

of CCI 221.01, “Medical Accession Standards,” Appendix A, to determine

the health qualifications of applicants.

b. Applicants to the Ready Reserve Corps.

(1) Applicants to the Junior Commissioned Officer Student Training and Extern

Program (JRCOSTEP) are required to undergo an abbreviated medical

evaluation process to include submission of a full medical history and a

verified height and weight.

(2) All other applicants for a commission in the Ready Reserve Corps,

including applicants to the Senior COSTEP, are required to undergo the

same medical evaluation process as applicants to the Regular Corps.

CCI 221.02 Medical Readiness 12 June 2019

c. Applicants to the Regular Corps and to the Ready Reserve Corps.

(1) An applicant who has a disqualifying medical condition may be granted an

applicant medical waiver of the disqualifying condition(s). The waiver

authority for applicants rests with the SG or his/her designee. A request for

consideration of a medical waiver may be initiated by the Service Medical

Officer (SMO) at DODMERB who disqualified the applicant or by MA when

MA is responsible for determining the medical qualifications of an applicant.

The decision of the waiver authority is final and cannot be appealed.

(see CCI 221.01 and POM 821.72, “Waiver of a Disqualifying Medical or

Dental Condition”).

(2) Before an appointment and/or before entry on active duty, all applicants to

the Corps are required to notify MA immediately of any change in health

status occurring after submission of any medical information.

(3) Failure to disclose any medical information and/or adhering to the

requirements of this Instruction will result in terminating the processing of

an application. If failure to disclose is discovered after a call to active duty,

an individual appointed to the Regular Corps may have his/her commission

terminated in accordance with CCD 123.01, “Involuntary Separation,” and

an individual appointed to the Ready Reserve Corps may be separated

from active duty by the Director, CCHQ.

d. Examinations of Active-Duty Officers.

(1) To ensure deployment readiness, all active-duty officers are required to

submit a Periodic Health Update (PHU) to document service incurred or

aggravated conditions and to promote attention to individual health

maintenance and disease prevention.

(2) The SG will determine the requirements of the PHU (see POM 821.71).

Basic requirements must include an updated medical history verified by a

healthcare provider, an annual dental examination, annual

alcohol/substance abuse screening, and an annual mental health

screening for depression and post-traumatic stress disorder (PTSD).

Additional testing is at the discretion of the examining healthcare provider

and is based on the individual needs of the officer and screening

examinations recommended by the United States Preventive Services

Task Force (USPSTF).

e. Retirement and Separation Examinations. A retirement or separation examination

is not required; however, it is in the officer’s best interests to obtain a final

examination prior to separating from active duty in order to document any service

connected conditions. Officers are advised to schedule the examinations to allow

sufficient time to obtain the results prior to the effective date of their retirement or

separation.

(1) Scheduling and obtaining a retirement or separation examination is the

officer’s responsibility.

(2) Because this is an officer’s final physical examination in the Corps, it is

important that this examination be thorough and complete. All positive

history should be well documented and, if not previously investigated,

work-up should be completed and recorded. In addition, copies of pertinent

records of any previous evaluations and treatments of significant medical

CCI 221.02 Medical Readiness 12 June 2019

conditions should be submitted directly to the Medical Evaluations

Section, MA, CCHQ.

(3) If, based on the examination, a question arises as to the officer’s fitness for

continuation on active duty if he/she were not separating, the Chief, MA,

should be notified (see CCI 393.01, “Medical Review Board”).

6-3. Requirements. The SG will determine the specific requirements of the medical

examinations, testing, and immunizations that must include, at a minimum, the following

(see POM 821.71):

a. Testing for Latent Tuberculosis Infection (LTBI). All applicants to the Regular Corps

and the Senior COSTEP must be tested for LTBI either by tuberculin skin testing or

by interferon-gamma releasing assay (IGRA). The following actions must be taken

depending on the test results:

(1) Applicants.

(a) Positive test: The applicant must be further evaluated by his/her

healthcare provider for the presence of active tuberculosis or LTBI.

If LTBI is diagnosed, the applicant must complete a full course of

tuberculosis preventive treatment unless medically

contraindicated.

(b) Equivocal test: The applicant must be further evaluated by his/her

healthcare provider to determine whether or not the applicant has

LTBI.

no ongoing medical condition that would significantly increase the

likelihood of a false negative test, the applicant will be considered

free of LTBI.

(2) Active Duty Officers. No LTBI testing is required unless the officer is

working at a duty station that is considered high-risk for tuberculosis and

the duty station requires regular surveillance or the officer has been

deployed to highly endemic area for tuberculosis. If the officer is required

to get LTBI testing, those results must be submitted to MA as part of the

officer’s PHU.

b. Immunizations. Vaccines are important tools that help protect the health of Corps

officers while serving at their assigned duty station and/or while engaging in

response activities.

(1) Officers are required to be immunized against: Measles/Mumps/Rubella

(MMR), Varicella, Tetanus/Diphtheria, Hepatitis A, Hepatitis B, and

influenza (annually). Newly commissioned officers have up to 12 months

after commissioning to complete Hepatitis vaccinations.

(2) Officers are required to submit proof of immunizations and boosters to MA.

The information must include: the date and type of vaccine(s)

administered; medical provider’s name, title/rank (if applicable), and

signature. It is also required that officers report their immunization

information using guidelines provided by MA on the CCMIS website.

CCI 221.02 Medical Readiness 12 June 2019

(3) Positive antibody titers confirming natural or acquired immunity are

acceptable proof of immunity for MMR and Varicella. Accompanying

medical documentation must be submitted to MA for confirmation.

(4) Influenza (annual). Officers are required to obtain an influenza vaccination

as soon as the vaccine becomes available during each influenza season.

Compliance with this requirement will be determined on 31 December of

each year and not on the anniversary date of the officer’s last influenza

vaccination. Officers who are deployed and/or assigned to the Southern

Hemisphere must follow the recommended regional influenza

immunization schedule with completion of the immunization by June 30.

(5) Officers are required to obtain vaccinations needed for deployment to

certain areas of the world.

(6) Officers are encouraged to obtain other vaccinations recommended in the

Centers for Disease Control and Prevention adult recommended

immunization schedule.

6-4. Examining Facilities. Active duty officers must arrange their PHU through their primary care

provider at the facility where they get their routine healthcare. Applicants who are not

examined through DODMERB should get their examinations through their regular

healthcare provider at the applicant’s expense.

6-5. Medical Readiness for Deployment In order to fulfill the mission and responsibilities of the

Corps, all officers must be able to be deployed to various environments and areas of need.

At a minimum officers must be able to:

a. Suspend any ongoing professional treatment (e.g. physical therapy, counselling) for

the period of the deployment without anticipated adverse health consequences.

b. Manage the physical and mental stress of deployment without anticipated adverse

health consequences.

c. Manage the dietary and environmental changes encountered during a deployment

without anticipated adverse health consequences.

d. The SG may establish additional health standards for officer deployability to

environments with limited healthcare and logistic resources.

6-6. Medical Waiver Program for Medical Readiness. There are times when an officer may

require a medical waiver due to a medical condition that affects his/her health status or

personal well-being. Such conditions may pose specific or general physical limitations or

restrictions on the officer’s ability to reach optimal medical readiness. Therefore, officers

may be medically exempt from meeting one or more of the standards for medical readiness

and/or Basic level of force readiness when a valid medical reason exists which is supported

by appropriate medical documentation.

a. The purpose of the Medical Waiver Program is to assist the Corps in implementing

the Department’s policy on medical and force readiness, while reducing

unintentional injuries due to the inappropriate application of an immunization or

physical readiness requirement. This program will be administered by MA within

CCHQ.

CCI 221.02 Medical Readiness 12 June 2019

b. Any officer who, because of a documented medical condition, cannot be deployed

or who cannot complete any of the cardiorespiratory endurance exercises of the

Annual Physical Fitness Testing (APFT) for 24 consecutive months is not eligible

for a medical waiver and must be referred to MA for review by a Medical Review

Board (see CCI 393.01, “Medical Review Board”).

c. Temporary time-limited medical waivers may be granted for a documented health

condition that is likely to improve within 12 months, or less, from the date that the

request was received by MA.

d. Permanent long-term renewable medical waivers may be granted for conditions

that are unlikely to improve in the foreseeable future, but do not prevent an officer

from performing, for more than two years, the cardiorespiratory endurance section

of the APFT or from being deployed. Examples of this type of waiver are for certain

immunizations which are contraindicated in individuals with severe egg allergies

or uniform (beard) waivers for individuals with certain chronic dermatologic

conditions.

e. Medical waivers are personal exemptions from performing or engaging in one or

more of the following activities:

(1) Deployment;

(2) Receiving one or more immunization;

(3) Performance of all or part of the APFT;

(4) Meeting weight standards;

(5) Maintaining uniform requirements (e.g., beard waivers, shoe waivers);

(6) Completing Basic Life Support training; or

(7) Fulfilling other requirements necessary for meeting and/or maintain the

Basic level of force readiness.

f. Clarification of Specific Medical Waivers.

(1) Pregnancy. Pregnancy waivers are in effect from the time of the receipt

in MA of the documentation of pregnancy until six months after the

anticipated date of delivery. Pregnancy waivers will automatically cover

exemptions for deployment, all sections of the APFT, weight standards,

BLS, and obtaining live virus vaccinations. The officer is expected to

complete/meet all waived readiness requirements within six months after

the termination of her pregnancy waiver.

(2) Breastfeeding. Breastfeeding waivers may be granted for deployment or

training which requires the officer to leave her home for more than

48 hours. Breastfeeding is not a medical justification for waiving all or part

of the APFT.

(3) Weight standards. Some medical conditions or treatments can contribute

to changes in weight or difficulty gaining or losing weight. When an officer

requests a weight standards waiver, his/her healthcare provider must

provide to MA evidence based data regarding the effects of the condition

CCI 221.02 Medical Readiness 12 June 2019

or treatment on weight. The officer must also provide a pretreatment

weight. If a waiver is granted, the extent of relaxing the standards will be

based on the documented effects of the treatment. MA will utilize

peer-reviewed medical literature to determine the effects of a treatment.

7. RESPONSIBILITIES:

7-1. The Examinee (i.e., officer or applicant).

a. Applicant Examinees are responsible for following all directives from DODMETS,

DODMERB, and MA. In addition, all applicant examinees are responsible for

arranging and paying for the required dental, laboratory, and other supplemental

examinations. It is also the responsibility of the applicant examinee to inform the

non-DODMETS examiners of the examination requirements and to provide

necessary forms to the examiners if these forms are not routinely used by the

examiners’ facilities. The applicant examinee is responsible for following all

instructions regarding the forwarding of examination forms to the appropriate

recipients.

b. Active Duty Examinees are responsible for arranging for completion of his/her PHU

(as outlined in the detailed requirements) through his/her primary care

manager (PCM). In addition, the active duty examinee is responsible for

completing a comprehensive medical history, an alcohol abuse questionnaire, a

depression screening questionnaire, and a PTSD screening questionnaire prior to

his/her PHU examination and to provide the completed forms to his/her healthcare

provider. The active duty examinee is responsible for following all instructions

regarding the forwarding of examination forms to the appropriate recipient.

7-2. The Examining Physician.

a. The medical provider examiner is responsible for reviewing the medical history and

performing additional testing including a physical examination, additional

laboratory testing, other studies, or consultations, as indicated. The dental

examiner is responsible for obtaining an updated dental history and examination.

b. Any provider not authorized to practice independently by virtue of either licensure

or facility policy, must have his/her notes countersigned by a supervising provider

who is authorized to practice independently. The examiner must assist the

examinee to obtain copies of all PHU documents.

7-3. Medical Affairs, CCHQ. MA, is responsible for the review, evaluation, and maintaining

documentation of an active duty officer’s latest PHU and for approving medical waivers. In

addition MA is responsible for determining an officer’s Medical Readiness Category for

deployment and identifying health conditions that have a strong likelihood of negatively

affecting an officer’s ability to do his/her duty, permanently or over an extended period of

time. MA is also responsible for the determination of the health qualifications of all

applicants who are not processed through DODMERB.

7-4. All officers and applicants are responsible for adhering to the guidelines established in this

Instruction.

8. HISTORICAL NOTES: This is the first issuance of this Instruction within the eCCIS and

creates a standalone Instruction within the eCCIS and replaces CCPM CC29.3.5 dated 24

October 1997.