fd-899 - 032010.pdf

FD-899

(Rev. 3-8-2010)

FEDERAL BUREAU OF INVESTIGATION

FBI HAZARDOUS MATERIALS RESPONSE

PHYSICIAN’S REPORT

Name: ____________________________________________________ Age: __________ Sex: _________

Employee ID#: ____________________________________________ Date examined: __________________________

Title/Position: ____________________________________________________

Findings:

There is no significant evidence of disease or health impairment

There is evidence of current disease or impairment that is

Not etiologically related to and/or aggravated by employment

Possibly etiologically related to and/or aggravated by employment

Most likely etiologically related to and/or aggravated by employment

Comments: _______________________________________________________________________________________

Recommendations (Please check all that apply):

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

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

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

Physician’s signature: ________________________________________

1- HCPU medical file copy 1- HMRU file copy 1- Agent copy