USACEOH-793 Medical Clearance Cover Letter.pdf

MEDICAL EXAMINATION CLEARANCE FORM 793

Employee:

Job Series:

MEDICAL CLEARANCE:

FULL MEDICAL CLEARANCE for the functional requirements of this position results have been reviewed with employee

CLEARANCE DENIED

CLEARANCE PENDING additional information.

Comment:_______________________________________________________________________________ Do not include medical diagnoses on this form. from

RESPIRATOR CLEARANCE:

District: _____________________

N/A Employee Not Enrolled in Respiratory Protection Program

TO BE COMPLETED BY THE EXAMINER/REVIEWER:

This employee has been found to be physically able to use the following (check each [ ] that applies):

Single use, filter mask (four attachment points) Full-faced powered cartridge-type (PAPR) Half-faced cartridge-type, negative pressure Self-contained breathing apparatus (SCBA) Full-faced cartridge-type respirator, negative pressure Hood/helmet powered cartridge-type (PAPR) Half-faced powered cartridge-type (PAPR) Half-faced/Full-faced/Hood/Helmet (NOT positive pressure)

This employee has been found to be physically NOT able to use a respirator

There is insufficient information to make a determination at this time.

The mandatory questionnaire has been reviewed, and the employee has been found to be physically able to use a respirator.

The mandatory questionnaire has been reviewed but there is insufficient information to make a determination at this time.

This respirator clearance expires ______ years from the date below. (If not marked, clearance expires in one year.

Last 4 of SSN: _________________

Hearing Conservation

Wildland Fire Management

CDL

FAA: Class ____

DIVER

Lock and Dam Operator

POST OFFER:

CRANEOPERATOR (see attached Crane requirements)

US Coast Guard: CG719K

HAZMAT (HAZWOPER Standard, 29 CFR 1910.120)

Food Handler

Respirator Fit Testing

Welder

I attest that I have reviewed the position functional requirements, exposures, and history and physical.

Examiner Signature: ___________________________________________________________________Date:____________ Printed Name: __________________________________________________________________________________________ CLINIC/ADDRESS: ______________________________________________________________________________ k5so9pbm Line k5so9pbm Line