Laserfiche WebLink
�EALTH STATUS REPT <br /> TYPE OF EXAMINATION <br /> ❑ Post-Offer Placement <br /> • GRE.9NEY MEDICAL GROUP ❑ Special Occupational <br /> OCCUPATIONAL MEDICINE ❑ Routine Periodic <br /> ENVIRONMENTAL HEALTH El Other TOXICOLOGY Spi <br /> KNIGHT, JAY Position Date of Exam <br /> 5SN: 465-55-6366 02/23/95 <br /> Employee DGA; 09/28/66 Location Supervisor <br /> EMG: CY,`I ENVIRONMENTAL <br /> Employer SRV: BE EIE <br /> IIll"Ill"111"J"ll111111111111111111111111!Ill 25-e02-23-03 Social Security No. <br /> The following recommendation is based on a review of base history questionnaire, diagnostic tests, physical examination <br /> and the essential functions of the position applied for or occupied by the individual named above. <br /> STATUS <br /> t. ZThe examination indicates no significant medical impairment can be assigned any work consistent with skills and training. <br /> 2. ❑ The examination indicates that a medical impairment currently exists that limits work assignments. <br /> ❑ Cannot perform an essential function (s) ❑ Must wear corrective lenses <br /> ❑ Work sitting only <br /> ❑ Day work only(no shift work) <br /> ❑ Not to lift over <br /> pounds ❑ No overtime <br /> ❑ No work requiring filter type respiratory protective device ❑ No repeated bending <br /> • ❑ No work in confined spaces ❑ Not to work with volatile oroanic <br /> compounds, solvents, or hepatotoxins <br /> ❑ No work with chemicals or irritants ❑ Not to work at a specific job or area <br /> Suggested accommodations <br /> (specify) <br /> Not to operate: ❑ Forklift ❑ Tow Motor <br /> ❑ Cannot perform marginal functions <br /> ❑ Passenger Vehicle ❑ Truck <br /> 3. ❑ Deferred,the examination indicated that additional information is necessary.Employee,given the following instructions: <br /> The following recommendations comply with Federal OSHA standards. <br /> Has the employee any detected medical conditions that would YF3 N_Q UNDECIDED <br /> increase his/her risk of material health impairment from occupa- <br /> tional exposure? ❑ ❑ <br /> Does the employee have any limitations int us of per nal <br /> protective equipment, (e.g. clothing or respir ors)., ! Cl ❑ <br /> ATE EXAMINER <br /> Signature M.D. <br /> 'The employee has been informed of the results of this examination. aG,Ht taeot <br />