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. ___________________________________

Type of Examination 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

_____ 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.

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

Appointments are scheduled 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 _____

I hereby authorize the use and/or disclosure of my individually identifiable health information as described below. I understand that the purpose of my visit is for the purpose of creating protected health information for disclosure to my employer, North Carolina State University. Should I refuse to sign this authorization, the examination requested will not be conducted, and certain tasks cannot be performed because they require a medical examination. If this task is an essential job duty, lack of performance may result in termination of my employment. I further understand that if the person(s) or organization authorized to receive the information is not a health plan or health care provider, the released information could be re-disclosed and would no longer be protected by federal privacy regulations.

1. Specific information to be disclosed: All medical information obtained as a result of the examination identified above.

2. Person(s) (or class of persons) or organization authorized to provide the information: Student Health Services, Duke Occupational Medicine, and ___________________________ (write in name of health care provider if not listed above or N/A for not applicable).

3. Person(s) or organization authorized to receive the information: My supervisor and the manager of industrial hygiene or Environmental Health and Safety occupational medicine program.

4. Purpose of the requested disclosure: To determine if employee has a health condition which may interfere with his/her job performance and to comply with OSHA regulations.

5. I understand that I have a right to revoke this authorization at any time. My revocation must be in writing in a letter provided to the Student Health Services. I am aware that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization.

6. I understand that I will get a copy of this form after I sign it.

7. I have been provided with a copy of NC State University’s Notice of Privacy Practice prior to signing this authorization. A copy of the Privacy Practice is located also on the EHSC’s Medical Surveillance webpage.

8. This authorization expires in one year.

____________________________________________ ___________

Signature of Employee Date

_____________________________________________ ___________

Signature of Supervisor (required for exam request, Date

NOT for release of medical information)