Attachment 3 - Medical Clearance Determination Form.pdf

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Medical Surveillance
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W911WN23Q3005
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Page of Version 1.0, NOV 2022

MEDICAL CLEARANCE DETERMINATION FORM

U.S. Army Corps of Engineers, Pittsburgh District This form must be completed and signed by a Qualified Occupational Health Physician specifying the employee's clearance for duty. Do not include any employee personal or medical information.

Exam Service(s) Performed:

Upon review of the Exam Service(s) performed, the employee is determined to be: (select one of the following) 6.4.0.20180228.1.932123.929382

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