OCCUPATIONAL HEALTH FACILITY
PHYSICAL EXAMINATION APPOINTMENT
NAME
DEPARTMENT
JOB TITLE
TITLE CODE
% OF TIME
PHONE
PROPOSED 1ST DATE OF WORK
DATE
Please report to Occupational Health Facility
For Physical Examination
TIME
Employee must bring copy of job description and if available, job analysis.
REHIRE
TRANSFER
NEW EMPLOYEE
OTHER
Signature of Supervisor/Dept. Head
DATE
OCCUPATIONAL HEALTH FACILITY ONLY
The above person was examined on the above date and the following was found/recommended:
A. Cleared without restrictions.
B. Cleared with the following restrictions: ____________________________________________________________________________
Prior to this time, candidate will be re-examined and a new
recommendation made.
D. Physical/Mental condition is such that employment advisable only under the condition in COMMENTS.
C. Approved only until
_________________________________
E. Physical/Mental condition makes employment in any capacity inadvisable.
F. Health evaluation incomplete. See COMMENTS.
G. Not cleared for non-medical reasons.
COMMENTS:
Signature:
UCLA Form #30174 Rev. (06/10)
NO
YES
EVIDENCE OF INFECTIOUS DISEASES (Explain below)
Date:
California License No.
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