Occupational Medicine Exam Request Form And Authorization For Release Of Medical Information printable pdf download

Occupational Medicine Exam Request Form And Authorization For Release Of Medical Information

N. C. State University, Student Health Services

Campus Box 7304, 2815 Cates Ave

Raleigh, NC 27695

919-513-0277

Occupational Medicine Exam Request Form

and

Authorization for Release of Medical Information

Last Name

_____________________________

First Name

__________________________

Date of Birth

_____________________________

Department

__________________________

Campus Tel. No. ____________________________

E-mail Address __________________________

Supervisor

______________________________

Supervisor’s Tel. No.

___________________

PeopleSoft Identification No. ____________________________ (see personnel rep. to get number)

Type of Service Requested (Check all items that apply)

_____ Respirator medical clearance exam (non-emergency respirator use: Class I exam*)

_____ Respirator medical clearance exam (emergency respirator use: Class III exam**)

_____ Pre-employment Physical

_____ Hearing Test

_____ Immunizations

_____ Nuclear Reactor Operator Exam

_____ Pfiesteria Use Exam

_____ Travel Clinic Services, include FAS no. ____________________

_____ Other (Please specify) ________________________________________________

*Class I Exam: for half and full face air purifying, powered air purifying, and supplied air respirators. Also

for SCBA use in changing out gas cylinders in labs. This exam is provided by Student Health Services.

**Class III Exam: for SCBA use in emergency response activities such as refrigerant gas leaks and

chemical spill response. This exam is provided by Duke Occ. Med. Employee may call Duke directly at 919-

286-3232 to schedule exam. This form must be signed and sent to Student Health Services.

Appointments for all except Class III exam are scheduled at Student Health Services on

Tuesday and Friday mornings. Every effort will be made to schedule an appointment within

two weeks of receipt of this form. Please indicate below your preference of days:

Tues. morning _____

Friday morning _____

Either Tues. or Friday _____

Please include second page with this form.

H/Forms/Medical Authorization, Rev. 7/04

Occupational Medicine Exam Request Form And Authorization For Release Of Medical Information

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