fd-899.pdf

FD-899 (4-15-99)

FBI HAZARDOUS MATERIALS RESPONSE

PHYSICIAN’S REPORT

Name: _________________________________________________________ Age: __________ Sex: _________

SSN: ________________________________________ Date examined: _______________________

Title/Position: ____________________________________________________

Findings:

G There is no significant evidence of disease or health impairment

G There is evidence of current disease or impairment that is

G Not etiologically related to and/or aggravated by employment

G Possibly etiologically related to and/or aggravated by employment

G Most likely etiologically related to and/or aggravated by employment

Comments: _________________________________________________________________________________________________

Recommendations (Please check all that apply):

G There are no limitations/restrictions of work activities for Hazardous Materials response

G Any type of respiratory equipment (including negative pressure respirators) may be used without restriction.

G Restrictions and/or follow up are necessary (see below)

Physician’s signature: __________________________________________

HCPU medical file copy (white) HMRU file copy (pink) Agent copy (blue)

FBI/DOJ

FD-899

Form is a 3-Part Carbonless 1 - White HCPU Medical File Copy 1 - Pink HMRU File Copy 1 - Blue Agent Copy