Healthcare OSHA Testing Form

HEALTHCARE OSHA TESTING FORM

Patient / Employee Information

Full Name:

Date of Birth:   Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance / Billing Information

Medical History (relevant to OSHA testing)

Pregnant or possibly pregnant? Yes No

OSHA-Mandated / Requested Tests

Select test(s) to be performed and provide specimen/test details. Multiple may apply.

TB Skin Test (PPD)   Date Administered:   Date Read:   Result (mm induration):

TB Blood Test (IGRA)   Specimen ID:   Date Collected:

Qualitative / Quantitative Fit Test   Method:   Respirator Model:   Result:

Baseline Serology (HBV, HCV, HIV as indicated)   Specimen ID:   Date Collected:

Post-Exposure Evaluation   Exposure Date:   Exposure Type:

Exposure & Incident Details (if applicable)

Yes No

Provider / Laboratory Results (to be completed by clinician or lab)

Authorization, Release and Acknowledgements

I hereby authorize the healthcare provider and laboratory identified by my employer to collect specimens and perform the OSHA-mandated tests indicated above. I authorize the release of test results and clinically relevant information to my employer, designated occupational health personnel, and treating clinicians for the limited purpose of fulfilling occupational safety regulations, exposure follow-up, and medical management. I understand that results will be maintained in my confidential medical record consistent with applicable law.

I acknowledge that the recommended tests have risks and benefits which have been explained to me as appropriate: risks may include minor pain, bruising, fainting with venipuncture, local reaction to skin testing, or other rare complications. I understand that I may withdraw consent at any time prior to specimen collection without penalty; however withdrawal may limit my employer's ability to meet regulatory obligations or to provide timely post-exposure management.

I authorize disclosure of test results related to workplace exposures to the extent necessary for exposure investigation, treatment recommendations, and regulatory reporting required by occupational safety authorities. I understand that sensitive health information will be handled in accordance with privacy protections and only disclosed as required or permitted by law.

By checking the box below I certify that I have read and understand the foregoing statements, that I am the individual identified on this form (or legal guardian/representative signing below), and that I consent to the specified testing and disclosures for occupational health purposes.

I authorize testing and limited disclosure as described above.

I acknowledge receipt of privacy practices relevant to occupational health testing and understand protections and limits to confidentiality.

Certificate of Patient / Authorized Representative

I certify under penalty of perjury that the information I have provided on this form is complete and accurate to the best of my knowledge. I understand the tests ordered are for occupational health purposes and that my employer will be informed of test results as necessary for compliance with occupational safety requirements.

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