CENTRAL MICHIGAN UNIVERSITY
COLLEGE OF SCIENCE AND TECHNOLOGY
MEDICAL EXAMINATION REQUEST
Date _______________
Employee Name __________________________________________________________
Soc. Sec. No. ____________________________________________________________
Department ______________________________________________________________
Job Classification _________________________________________________________
The above named employee of Central Michigan University has been assigned to work requiring the use of a respirator. It is requested the employee be given an initial/annual medical examination which shall include the following:
o1. A complete physical examination of all systems with emphasis on the respiratory system, the cardiovascular system and digestive tract.
o2. A chest roentgenogram (posterior - anterior 14 x 17 inches)
o3. Pulmonary function tests to include forced vital capacity and forced expiratory volume at 1 second.
o4. Any additional tests deemed appropriate by the examining physician.
The following information should be taken into consideration when evaluating the employee’s physical ability to function normally wearing a respirator.
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The employee’s duties related to the anticipated exposure are: |
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The employee’s anticipated exposure level is: |
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Type of respirator to be used: |
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Information from previous medical examinations: |
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It is requested that the examining physician provide to CHIP a signed written opinion containing the results of the medical examination.
____________________________________________ ________________
Name of person supplying above information Date