B.06.05 Attachment 11 - Report to Employer.pdf

MEDICAL SURVEILLANCE PROGRAM

MEDICAL HISTORY AND PHYSICAL EXAMINATION FORM

Part VI. Report to Employer (to be completed by the reviewer)

SSN (last 4)

EXAM DATE

NAME

AGENCY _____________________________

Medical Opinion: (check all that apply)

The employee has been informed of the following medical opinion.

[ ] No medical findings were noted that indicate work-related injury/illness.

Where nonwork-related significant findings were noted, a referral has been made at the employee’s expense.

[ ] Medical findings support a work-related injury/illness or hazardous exposure, see recommendations below.

[ ] Medical findings or exposure history warrant a review of work activities, see recommendations below.

[ ] Decision deferred, additional documentation needed. Please provide the documentation listed below.

[ ] Work limitations recommended. (Specify limitations and re-evaluation date below).

Comments/Recommendations/Limitations:

Limitations should be reevaluated (Date)

Clearances:

[ ] Employee has been cleared for the routine duties outlined in the provided job description.

[ ] Commercial Drivers License (CDL/DOT) [ ] Crane Operator and Load Handling Equipment (LHE) [ ] U.S. Coast Guard License Holder [ ] Work Requiring Arduous Exertion [ ] Other (speficy):

Next Exam Due by: ___________ Expires

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

(see Respirator Medical Evaluation Questionnaire form for specific types and uses requiring clearance)

When wearing a respirator, the employee has been informed to limit activity level* to the following (check one [ ]):

[ ] Mild Exertion [ ] Moderate Exertion [ ] Heavy Exertion (No specified limitations)

Other limitations needed (if any) when wearing a respirator:

This respirator clearance expires on Enter date

□ 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 following additional tests, or medical information, will be required in order to make a determination regarding the safe use of a respirator by this employee:

Reviewer’s Name (Print) Reviewer’s Signature Date

* Light/Mild exertion (2-3 METS)= negligible lifting, extended walking (flat surface), extended standing, writing

Moderate exertion (4-5 METS) = lifting 10lbs (5 or more lifts/min), fast walking (4mph), gardening/digging, pushing, pulling Heavy exertion (5-10 METS) = jogging (10 minute mile), chopping wood, climbing hills, life-saving activities, firefighting

[ ] Single use, filter mask (four attachment points) [ ] Full-faced cartridge-type respirator, negative pressure [ ] Full-faced powered cartridge-type (PAPR) [ ] Hood/helmet powered cartridge-type (PAPR)

[ ] Half-faced cartridge-type, negative pressure [ ] Half-faced powered cartridge-type (PAPR) [ ] Self-contained breathing apparatus (SCBA) [ ] Half-faced/Full-faced/Hood/Helmet

(NOT positive pressure) (positive pressure airline respirator)

(select one box □ and provide comments as appropriate)

Expires Expires Expires Expires Expires

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