Appendix J
Medical Consultation Request
MEDICAL CONSULTATION REQUEST
1.
N a m e o f e m pl o ye e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2.
Employee Social Security No. ___________________________________
3.
Dat e of exposure i nci dent _________ _________ _______ _ _________ _
4.
Identity of hazardous chemical to which the employee was exposed:
________________________________________________________________________
5.
Amount and length of exposure: ________________________________
____________________________________________________________
6.
First aid rendered at time of exposure: ____________________________
_____________________________________________________________
7.
Signs or symptoms experienced by employee relating to exposure:
______________________________________________________________________
8.
Employee Signature: _______________________
Date: ____________ ___
The attending physician shall give the employer a written opinion stating:
1. Any recommendations for treatment or followup.
2. The results of the examination.
3. Any medical condition revealed which may put the employee at increased risk as a result of
exposure to a hazardous chemical.
4. A statement that the employee has been informed of the results of the exam.
Appendix J
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