29 CFR 1910.1053 a Written Medical Report for Employee Sample Form

WRITTEN MEDICAL REPORT FOR EMPLOYEE

PAPERWORK REDUCTION ACT STATEMENT

Under the respirable crystalline silica standards, it is mandatory for employers to ensure that a physician or licensed health care professional (PLHCP) or specialist provide employees who meet the medical surveillance trigger with a written medical report within 30 days of each medical examination performed. (29 CFR 1910.1053(i) and 29 CFR 1926.1153(h)). Under the Paperwork Reduction Act, a Federal agency generally cannot conduct or sponsor, and the public is generally not required to respond to, an information collection, unless it is approved by OMB and displays a valid OMB Control Number. Use of this sample medical report is entirely optional. This sample form will assist both the PLHCP or specialist and employers to ensure that the PLHCP or specialist provides compliant employee medical documentation. OSHA estimates employer burden for the completion of this collection of information is fifteen minutes. These estimates include the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and, completing and reviewing the collection of information. The time estimate includes time for a worker to wait for the completion of forms by a PLHCP (for both the medical report for the employee and medical opinion for the employer combined) and for the PLHCP to provide the report to the worker and the opinion to the employer. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to OSHAPRA@dol.gov or to OSHA’s Directorate of Standards and Guidance, Department of Labor, Room N-3718, 200 Constitution Ave., NW, Washington, DC 20210; Attn: Paperwork Reduction Act Comment; 1218-0266. (This address is for comments regarding this form only; DO NOT SEND ANY COMPLETED SAMPLE FORM TO THIS OFFICE.)

OMB Approval# 1218-0266; Expires: 00-00-0000

EMPLOYEE NAME: ____________________________________ DATE OF EXAMINATION: _______________

TYPE OF EXAMINATION:

[ ] Initial examination [ ] Periodic examination [ ] Specialist examination

[ ] Other: _______________________________________________________________________________________

RESULTS OF MEDICAL EXAMINATION:

Physical Examination – [ ] Normal [ ] Abnormal (see below) [ ] Not performed

Chest X-Ray – [ ] Normal [ ] Abnormal (see below) [ ] Not performed

Breathing Test (Spirometry) – [ ] Normal [ ] Abnormal (see below) [ ] Not performed

Test for Tuberculosis – [ ] Normal [ ] Abnormal (see below) [ ] Not performed

Other:___________________ [ ] Normal [ ] Abnormal (see below) [ ] Not performed

Results reported as abnormal: ____________________________________________________________________

__________________________________________________________________________________________________

[ ] Your health may be at increased risk from exposure to respirable crystalline silica due to the following:

_________________________________________________________________________________________________

RECOMMENDATIONS:

[ ] No limitations on respirator use

[ ] Recommended limitations on use of respirator: ________________________________________________________

[ ] Recommended limitations on exposure to respirable crystalline silica: ______________________________________

_________________________________________________________________________________________________

Dates for recommended limitations, if applicable: _______________ to _____________

MM/DD/YYYY MM/DD/YYYY

[ ] I recommend that you be examined by a Board Certified Specialist in Pulmonary Disease or Occupational Medicine

[ ] Other recommendations*: __________________________________________________________________________

__________________________________________________________________________________________________

Your next periodic examination for silica exposure should be in: [ ] 3 years [ ] Other: ___________________

MM/DD/YYYY

Examining Provider: ________________________________________ Date: _____________________

(signature)

Provider Name: ___________________________________________

Office Address: ____________________________________________ Office Phone: ___________________

*These findings may not be related to respirable crystalline silica exposure or may not be work-related, and therefore may not be covered by the employer. These findings may necessitate follow-up and treatment by your personal physician.

Respirable Crystalline Silica standard (§ 1910.1053 or 1926.1153)