Employee Exposure Certification

EMPLOYEE EXPOSURE CERTIFICATION

Personal Information

Position Information

Exposure Incident Details

Date of alleged exposure:

Time of exposure (approx.):

Suspected Agent / Source (check all that apply)

Did you seek medical attention? Yes No

Witnesses

Employment History (most recent)

Education

References (Professional)

Legal Disclosures and Authorizations

At-Will Employment: I understand that, unless otherwise provided in a written agreement signed by an authorized representative of the employer, my employment is at-will and may be terminated by me or the employer at any time, with or without cause or notice.

Equal Employment Opportunity: The employer maintains a policy of equal employment opportunity. Employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, or any other protected characteristic.

Authorization to Contact References and Prior Employers: By signing below I authorize the employer to contact the references and prior employers listed above to verify information relevant to my employment and workplace safety, and I release those parties from liability for providing such information in good faith.

Medical Release for Occupational Health: I authorize release of medical information related to this exposure to the employer, the employer's designated occupational health provider, and workers' compensation administrators as required for treatment, testing, and claims processing. I understand that such information will be used only for legitimate occupational health and safety purposes and will be handled in accordance with applicable privacy laws.

Consent to Testing: I consent to any medical testing reasonably necessary to evaluate exposure, including blood draws, swabs, imaging, or other diagnostic procedures required by the employer's occupational health protocols or applicable regulatory requirements.

Confidentiality and Records: Records related to this incident will be maintained as required by law and employer policy. While the employer will protect medical confidentiality to the extent practicable, limited disclosure to supervisory personnel, safety officers, insurance carriers, or regulatory authorities may be required.

Employee Certification and Acknowledgment

I certify under penalty of perjury that the information I have provided in this Employee Exposure Certification is true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false information may result in disciplinary action up to and including termination.

I further acknowledge that I have been informed of my right to receive follow-up medical evaluation and testing, and that I will comply with any reasonable instructions given by the employer or its occupational health provider related to monitoring, work restrictions, or return-to-duty requirements.

I authorize the employer to report the exposure to appropriate internal personnel and regulatory authorities if required by law. I understand this certification may be used as part of a workers' compensation or safety investigation and I waive any expectation that the investigation will be kept confidential beyond legally required protections.

Employee Authorization (select all that apply)

Additional Notes (investigative use)

Applicant Certification (Employment Information Verification)

I certify that all employment history, education, and reference information provided on this form is true and complete. I understand that the employer may verify this information and that falsification or omission of facts may result in an adverse employment action.

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