Healthcare Mold Clearance Form

Healthcare Mold Clearance Form

Purpose: This form documents clinical evaluation and environmental information related to suspected or confirmed mold exposure and provides a written determination regarding the individual's clearance to occupy or return to the affected environment. The evaluating clinician will record findings, test results, and recommendations. Patient signature at the end constitutes authorization for release of the contained clinical findings to relevant parties for the purpose of remediation verification and safe re-occupancy planning.

Patient Information

Patient Name:

Date of Birth:    Gender: Male   Female   Other

Insurance Information

Exposure / Incident Details

Date(s) of Exposure:

Visible Mold Present: Yes   No    Water Damage Observed: Yes   No

Remediation Completed: Yes   No    If yes, remediation completion date:

Symptoms Assessment

Check all current symptoms experienced since exposure:

Cough   Wheezing   Shortness of breath   Nasal congestion

Headache   Eye irritation   Skin rash   Fatigue

Medical History

Immunocompromised Status: Yes   No    If yes, please explain:

Clinical Examination & Tests (Clinician Entry)

Spirometry Performed: Yes   No    If performed, summary of results:

Chest Imaging Performed: Yes   No    If performed, date and summary:

Environmental Assessment

Environmental Testing Conducted (air, surface, bulk): Yes   No

Clearance Determination (Clinician Recommendation)

Based on the clinical evaluation and available environmental information, the evaluating clinician recommends:

Cleared to return to the affected environment without restrictions.
Cleared to return with restrictions/modifications (describe below).
Not cleared to return at this time (medical reason must be provided).

Acknowledgment, Authorization & Privacy

I certify that the information I have provided is accurate to the best of my knowledge. I authorize the evaluating clinician to release findings, restrictions, and clearance status to my employer, building owner, remediation contractor, or other designated parties when necessary for purposes of remediation verification and safe re-occupancy. I understand that this information will be handled in accordance with applicable privacy laws and facility policy.

Patient acknowledges receipt of privacy notice and understands the limits of confidentiality related to workplace reporting and public health requirements: Acknowledged

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