Why and How do Organizations Focus on Pre-Placement Medical Exams?

Companies in the United States are increasingly turning their attention to how employee health influences the cost of work-related and non-work related illness and injury. In a survey of safety and health professionals conducted in November, 2014, by Industrial Safety & Hygiene News magazine, about one in three (32 percent) of the surveyed professionals said that employee lifestyle health issues (high blood pressure, high cholesterol, diet, obesity, smoking, drug and alcohol abuse, etc.) demand more attention in the workplace. Employees who are not well matched to the physical requirements of the job increase risk for organizations.

A critical decision: Hiring the “right” people

There is an important strategy that can reduce occupational illnesses and the related costs, improve employee health behaviors, and improve overall business efficiency and productivity. This can be done by ensuring that employees coming into new jobs have the physical and mental capacities to accomplish essential functions of the job. This strategy is particularly relevant given that monthly new hires are expected to continue to climb in 2015 in the United States, as the economy continues to bounce back from the Great Recession of 2007-2009. Unemployment is down, and the search for talented, skilled labor is on. About four in ten safety and health professionals (38 percent) surveyed by Industrial Safety & Hygiene News said a shortage of skilled labor will be a problem in their workplace in 2015. Hiring the “right” people for the “right” job is now a high-stakes challenge.

“Pre-offer” vs. “Post-offer” or “Pre-placement”

Pre-placement medically-related questions and examinations have numerous benefits, but the Americans With Disabilities Act of 1990 (ADA) makes it absolutely clear that under the law, you must not ask medically-related questions and must not conduct medical examinations until after you make a conditional job offer to the applicant. Once a conditional job offer is made, a licensed healthcare professional can ask questions relating to physical and mental health, and can require a medical examination, as long as this is done for all entering employees in that job category. If an individual is deemed unable to safely perform the essential job functions with or without accommodation, it must be shown that the medical condition poses a direct threat to the applicant’s safety, according to the U.S. Equal Employment Opportunity Commission (EEOC). This means that the person poses a significant risk of substantial harm to him/herself or others, and that you cannot reduce the risk below the direct threat level through reasonable accommodation.

Safety risk comes into play in many occupations such as machinery operators, construction workers, public transportation personnel (e.g. airline pilots, truckers, railroad engineers, and bus drivers), hazmat workers, chemical manufacturing and processing personnel, food processing workers, maintenance personnel, employees working at unprotected heights, and many other jobs.

Drug and alcohol tests

Ordering pre-placement drug tests on applicants is a good way to decide if you should bring a candidate on board or rescind the offer of employment. Drug and alcohol abuse costs employers $81 billion annually, according to the National Council on Alcoholism and Drug Dependence, Inc. This is in addition to the potential for workplace fatalities and serious, life-altering injuries, and hospitalizations.

OSHA requirements

Pre-placement medical evaluations should follow OSHA standards if appropriate. For instance, if the worker will be required to handle hazardous materials, the examination should follow the OSHA Hazardous Waste Operations and Emergency Response Standard. If respirator use is required, the examination should adhere to OSHA’s Respiratory Protection Standard. If loud noise exposure is anticipated, hearing tests should adhere to OSHA’s Hearing Conservation Standard.

Here are 4 examples of how pre-offer and post-offer differ:

In the pre-offer stage you may not ask how many days an applicant was previously out-of-work on sick-leave, nor can questions be asked about previous job-related injuries, or workers’ compensation claims. These types of questions might elicit information about disabilities, and the law prohibits hiring discrimination based on disabilities. 

In the pre-offer period you can require applicants to lift a 30-pound box and carry it 20 feet. This is not a medical examination, but a test of whether the applicant can perform essential job functions. However, if you take the applicant’s blood pressure or heart rate after the lifting and carrying, the test would be a medical examination because it is measuring the applicant’s physiological response to lifting as opposed to the ability to lift and carry.

Similarly, in the pre-offer phase, a physical fitness test, such as running or lifting, would not be a medical examination if it solely measures an applicant’s performance. A test for a messenger service might be to run a mile in less than 15 minutes, but if you measure an applicant’s physiological or biological responses to running, the test would be medical and disallowed.

Evaluating someone’s ability to read labels or distinguish the colors of wires as part of a demonstration of the person’s ability to do essential job functions is not a medical examination. However, an ophthalmologist’s or optometrist’s analysis of someone’s vision is considered medical, and not permitted during the pre-offer period.

After the job offer…

Your company’s job offer may be conditioned on the results of post-offer medical examinations. For instance, a person with medically diagnosed claustrophobia might not be suited for a job requiring all-day respirator usage, since claustrophobia is the most common cause of problems with respirator use, according to NIOSH. Individuals with health issues such as a heart condition, chronic lung disease, diabetes, or seizures, may be put at increased risk if the job entails working in hot dusty environments,  strenuous work, long hours that induce fatigue, exposure to hazardous agents, unprotected heights, confined space entry, or work involving altered eating and sleeping patterns.

Health risks revealed

Health risks that can be identified through pre-placement medical examinations include obesity, hypertension, diabetes, heart disease, vascular disease, neurologic disorders, gastrointestinal diseases, anxiety or depression, and the use of impairing/sedating drugs such as antihistamines, narcotics, psychoactive drugs, and tranquilizers.

Physical examinations may vary, but the basic components, according to NIOSH, are:

  • applicant demographics (age, gender, etc.)
  • physical examination (including blood pressure, pulse, respiration, temperature, height, weight)
  • review of systems (head/neck, heart/lungs, gastrointestinal, genitourinary, skin and soft tissue)
  • ancillary tests (depending on job description, employer requirements, patient age, etc.)
  • vision screening
  • hearing screening.

The World Health Organization (WHO) recommends conducting pre-placement physicals in these four situations: when hiring employees to work in hazardous environments; if a particular job requires a high level of fitness; when the safety of other workers and/or the public may be at risk; and if the physical is required by law.


Ignorance of employees’ health status is dangerous, both for you as an employer, and for the individual. According to NIOSH, benefits of pre-placement evaluations include:

  • Proper pairing of the applicant to the essential functions of the job.
  • Discovery of health condition(s) that may place the safety or health of the applicant or others at increased risk.
  • A basis for determining needs in the area of reasonable accommodation (e.g.  sensory aids, special workstations, additional tools or devices, engineering controls, and/or special parking).
  • Introduction of an employee to health and wellness initiatives of the company.
  • Documentation of baseline of health status so that future exams can determine whether any occupational exposures have affected the employee's health.
  • Assessment of baseline psychological status so that proper referral to counseling resources (e.g. Employee Assistance Program) can avert future job-related difficulties.

A culture of health promotion

Beyond statutory requirements and cost-containment considerations, pre-placement medical examinations are an excellent strategy for raising employees’ personal health awareness, and providing employees with information and incentives to adopt healthy behaviors and attitudes both on and off the job. In many respects it is a proactive and preventive strategy, rather than a reactive one. In the future, data gleaned from pre-placement medical examinations will support the growing popularity of self-monitoring one’s health through wearable sensor technologies such as buttons, badges, wristbands, eyeglasses, “smart clothing”, or anything else that can be worn or hooked onto the body and embedded with sensors to detect and measure various health parameters.


Pre-placement physical exams are a cost effective means to ensure that new hires are physically and mentally capable of performing the essential functions of the job. AllOne Health Corporate Medical Director, Fred Kohanna, MD, MBA, FACOEM, has found that “it is not uncommon for me and my team to discover undiagnosed health problems such as diabetes and high blood pressure during the pre-placement exam process.” A small expenditure up-front, saves on future Workers’ Compensation, Group Health insurance, STD, and LTD costs, ensures regulatory compliance, fosters a drug-free workplace, minimizes future health related losses in productivity, identifies medical and lifestyle risk factors that employees can begin to address, and introduces employees to company sponsored wellness and health promotion initiatives.