PWS Appendix E - MD Report.pdf

REPORT TO EMPLOYER

Name: DATE:

Results of Your Medical Surveillance Test

Physical Examination: Normal Other N/A Not Received

Electrocardiogram: Normal Other

N/A Not Received

Lab Test: Normal

Other N/A Not Received

Drug Screening: Normal Other N/A Not Received

Pulmonary Function Test: Normal Other N/A Not Received

X-Ray Results: Normal Other N/A Not Received

All Studies are within normal range, individual is medically cleared for employment.

The abnormal values found may potentially be related to the position and occupational exposures. Coordinate retest with the Safety Office.

The abnormal values are not thought to be a result of occupational exposure. The individual should make their personal physician aware of the results at their own expense. A copy of the results were provided to the individual for review with their physician or care provider.

Approved for work with the recommendations/actions indicated below.

At this time the values indicate the individual is not medically cleared for employment.

Notes:

PHYSICIAN NAME

ADDRESS

CONTACT INFORMATION

Continued on back of page

Name: DATE:

PHYSICIAN NAME

CONTACT INFORMATION