OHSP APPENDIX VIII

George Mason University

Medical Monitoring Examination Employer Notification

Employee: ________________________________ Date: ____________________

Employer: ___________________________________________________

I have reviewed the results of this individual’s medical monitoring examination and clarify that the record:

( ) is ( ) is not complete.

Test not performed: __________________________________________________________________

Please check all sections that are applicable to this examination.

NOT

APPLICABLE APPLICABLE

[ ] [ ] Working with animals

Species: _______________________

[ ] [ ] Respirator Certification:

This individual has been examined as per OSHA Standard 29 CFR 1910.134 and found:

( ) qualified ( ) not qualified to use a respirator.

Comments:

Please describe any work limitations, including functional and environmental limitations, whether temporary or permanent, pending medical evaluation, which would eliminate one from working with animals.

I have informed the employee about medical conditions discovered during my examination that require further examination or treatment.

Signature: ___________________________________ Date: ____________________