The physician must inform the employee of the results of the examination and provide the University with a written opinion.
The Physician must complete the following information, either on this form or on a separate attachment and must not reveal specific findings of diagnoses unrelated to occupational exposure.
Physician's name:
Employee's name:
Date of visit:
Description of incident:
Recommendations for further medical follow-up? _____ Yes _____ No Please
explain.
Results of the medical examination and associated tests:
Was there any medical condition discovered which might place the employee at increased risk due to the hazardous chemicals found in the laboratory?
____ Yes _____ No. Please explain.
Additional Comments:
The employee has been informed of the results of the medical examination and
any medical condition that may require further examination or treatment.
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Physician's Signature: __________________ |
Date: ________________ |