Attachment 5 Refusal of Medical Services.pdf

Attachment 5

REFUSAL OF MEDICAL SERVICES

(Occupational Health Nurse) (Medical Provider) (Date)

Medical Providers will assure that employee: (1) Selects appropriate part(s) from the choices (part A-E) below.

(2) Understands acknowledgement(s) in the part(s) selected.

(3) Initials each applicable acknowledgment statement.

(4) Signs and dates this form.

Part A: Periodic Medical Examination

� I understand I am required to have a periodic physical examination as a condition of employment:

� I decline the use of the current medical provider for my physical and choose to go, at my own expense, to my personal medical doctor.

� I will provide the results of that physical, including copies of all medical tests, to the Medical Provider’s Occupational Health Nurse within 30 days of signing this form.

� I understand the physical must be IAW the current DSCC Occupational Safety and Health Program.

� I understand refusal to attend, report for, or provide results of a periodic medical surveillance exam will subject me to unfavorable personnel action, including discipline.

Part B: Hepatitis B Vaccination (29 CFR 1910.1030 App. A)

� “I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself.

However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.”

Part C: Bloodborne Pathogens Exposure

� I understand I have been exposed to blood/body fluids, which may contain the Human Immunodeficiency Virus (HIV) / Hepatitis B

Virus (HBV). I have been advised of the related risks that may be associated with them.

� I refuse the HIV blood test.

� I refuse the HBV test.

Part D: Work-Related Injury

Under the provisions of Title 20, Part 10, Section 4 of the Code of Federal Regulations, I understand:

� I have the right to select a qualified physician to provide treatment of my work-related injury/illness.

My treating physician will be __________________________________________________________________________.

� Should I wish to change medical provider at a later date, I must obtain approval for the change from the Office of Worker’s Compensation Programs.

Part E: Treatment Refusal

� I refuse any type of treatment at this time.

The signature below indicates that I understand the statement(s) initialed above.

(Type of Print Employee Name) (Employee Signature) (Date)