Attachment 13 CLIN sheet .docx
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- Occupational Health Services
- Solicitation number
- SP4702-11-R-0001
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MEDICAL SERVICES CLIN SHEET
| NAME | ORG | |||
| BIRTH | ACTIVITY | Supervisor | Phone | |
| SERIES 2810 | TITLE: | WORKSITE | ||
| Dust Respirator | CD | BBP | ||
| #Exposure | #Exposure | |||
| Asbestos | ||||
| Hydrocarbons: | ||||
| Zinc: |
| PCB |
| Coal Tar Pitch |
| Acids: |
| Skin: |
| Photographic |
| Lead: |
| Pesticide |
| Silica: |
| Copper |
| Solvents: |
| Arsenic: |
| Chromate |
| Physical |
| Carbon |
| Carcinogens: |
| POL's: |
| Diesel: |
| Noise: |
| Hexan |
| Carbon |
| Smoke |
| Trichlorethan |
| Nickel: |
| Infectious |
| Freon: |
| Cadmiu |
| Dusts: |
| Iron: |
| Berylliu |
| #Exposure Potential: H=Historical, D=Daily, R=Regular Periodic(>8hrs/week), I=Irregular(>8hrs/week), O=Occasional(<8hrs/week), | |
| N=Not exposed, Defa=Exp to defatting agent, Irr=Exp to skin irritant, Pest=skin exp to pesticide, UV=Skin exp to ultraviolet light | |
| EXAM / SERVICE DATE: _________________ | Required Service(s) CLIN 5057 |
| No. | |
| Description | |
| Performed | |
| Date | |
| No. | |
| Description | |
| Performed | |
| Date |
| 3 |
| Physical Examination |
| 27 |
| Beta 2 Microglobulin |
| 4 |
| Injury/Illness Eval. |
| 28 |
| Creatinine (Urine) |
| 5 |
| Audiogram |
| 29 |
| Renal Panel |
| 6 |
| Masking Audiogram |
| 30 |
| Pregnancy Test (Urine) |
| 7 |
| Pulmonary Function |
| 31 |
| Malaria Pills,Mefloquine |
| 8 |
| EKG |
| 32 |
| Malaria Pills,Chloroquine |
| 9 |
| CXR, w/B read |
| 33 |
| Malaria Pills,Doxycyline |
| 10 |
| X-ray CXR/Extremity |
| 34 |
| Typhoid Vaccine |
| 11 |
| X-ray, Panorex |
| 35 |
| Meningococcal Vaccine |
| 12 |
| X-ray Head/Spine |
| 36 |
| Japanese Encep. Vac. |
| 13 |
| Splints |
| 37 |
| Yellow Fever Vaccine |
| 14 |
| Blood Lead |
| 38 |
| Hepatitis A Vaccine |
| 15 |
| Zinc Protoporphtrin |
| 39 |
| Hepatitis A Titer |
| 16 |
| Complete Blood Count |
| 40 |
| Hepatitis B Vaccine |
| 17 |
| Blood Chemistry |
| 41 |
| Hepatitis B Titer |
| 18 |
| Cholinesterase |
| 42 |
| Hepatitis C Titer |
Qtr 1
| 43 |
| Varicella Vaccine |
Qtr 2
| 44 |
| Varicella Titer |
Qtr 3
| 45 |
| Rubella Titer |
Qtr 4
| 46 |
| MMR Vaccine |
| 19 |
| Carboxyhemoglobin |
| 47 |
| Diptheria Vaccine |
| 20 |
| HIV Blood Test |
| 48 |
| Polio Vaccine |
| 21 |
| PPD (Tuberculosis) |
| 49 |
| Tetanus USE TDAP |
| 22 |
| Urinalysis w/micro |
| 50 |
| Pre-rabies Vaccine |
| 23 |
| Urinalysis Dip |
| 52 |
| Psychiatric Evaluations |
| 24 |
| Military Urine Collect |
| 53 |
| OHP Consultation |
| 25 |
| Cadmium (Blood) |
| 54 |
| FW Comp. Case Eval. |
| 26 |
| Cadmium (Urine) |
| 56 |
| Fasting Lipids |
| 58 |
| Mammogram |
| 57 |
| G6PD |
| 59 |
| Pap Smear |
| 60 |
| TDAP |
| 61 |
| HgbA1C |
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ATTACHMENT 13
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