Healthcare Hulling Plant

HEALTHCARE HULLING PLANT OCCUPATIONAL HEALTH CONSENT & MEDICAL SURVEILLANCE FORM

Facility and Visit Details

Facility Name:    Location/Plant ID:

Date of Visit:    Department/Unit:

Patient / Employee Information

Sex / Gender: Male Female Other

Employment & Exposure Information

Use of respiratory protection: Yes No    Frequency:

Insurance & Primary Care

Medical History

Please check any chronic conditions that apply:
Asthma COPD Diabetes Hypertension Chronic skin disorder

Surveillance Procedures, Risks, and Consent

I authorize Healthcare Hulling Plant occupational health personnel and/or their designated medical providers to perform the following as indicated by workplace protocol: focused history and physical examination; spirometry (breathing test); audiometry (hearing screening); skin examination; blood draw for routine tests; and immunizations or titers as required for job duties. These procedures are performed for early detection of work-related illness and to ensure fitness for duty.

I understand the nature and purpose of the indicated procedures, that minor discomfort or risks (such as transient lightheadedness from blood draw, minor irritation from spirometry or vaccination site soreness) may occur, and that more significant adverse events are uncommon. I have had the opportunity to ask questions about the procedures and risks.

I consent to the procedures indicated by occupational health staff and to any immediate emergency treatment deemed necessary in the event of an adverse reaction. I understand I may withdraw consent at any time by notifying the occupational health provider, except that withdrawal will not affect the lawfulness of actions already taken with my prior consent.

Spirometry / Pulmonary Function Test Audiometry / Hearing Screening Skin Evaluation Blood testing (CBC, chemistries) Vaccinations or titers

Release of Medical Information & HIPAA Acknowledgment

I authorize release of relevant medical information, including surveillance test results and work-related health findings, to the employer's designated occupational health administrator and to my treating healthcare providers as necessary to manage my health and fitness for duty. Such disclosure is limited to information necessary for workplace health and safety determinations.

I acknowledge receipt of the facility's privacy practices notice and understand how my protected health information will be used for occupational health purposes. I understand this authorization is voluntary and that refusal to sign will not affect my ability to receive treatment, but may affect my placement in safety-sensitive duties.

I authorize the release of medical information to the following additional persons or entities (optional):

Attestation

By signing below, I attest that the information I have provided on this form is complete and accurate to the best of my knowledge. I understand that falsification of medical or exposure history may impact the validity of occupational health recommendations and my fitness for work. I agree to follow recommended restrictions and follow-up as advised by the occupational health clinician.

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