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Form Test
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Form Test
Employee Name
(Required)
First
Last
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Employee Email Address
If email address is entered, employee will receive notification with instructions and address for Work Health Solutions
Company
(Required)
Company Contact Name
(Required)
Company Contact Phone Number
(Required)
Company Contact Email Address
(Required)
Reason for Visit: Please select only one
(Required)
Workers' Compensation Injury Treatment
Pre-Employment Services
Surveillance Testing (Audiogram, Respiratory, etc.)
Substance Abuse Testing ONLY (Post Accident, Random, Reasonable Suspicion, Cause, Follow-Up, Return to Duty)
DOT Exam Recertification
Fitness for Duty Exam (Job Description Required)
Return to Work Exam (Medical Records and Job Description Required)
Medical Record Evaluation
Independent Medical Examination (IME)
Other
If "other", please specify:
Send Bill to:
(Required)
Employer
Work Comp Insurance
Physical Exam:
DOT
Non-DOT
Silica
Other
Physical Abilities Test/ Job Function Test:
Pre-Placement
Fit for Duty
Lift Test (Per Company Protocol)
If "other", please specify:
If "other", please specify:
Substance Abuse Testing:
WHS - 5 Panel Rapid Minus THC (Non - DOT)
WHS - 5 Panel Rapid (Non - DOT)
WHS - 10 Panel Rapid Minus THC (Non - DOT)
WHS - 10 Panel Rapid (Non - DOT)
WHS - Lab Based - 10 Panel + Fentanyl (Non - DOT)
WHS - Lab Based - 10 Panel (Non - DOT)
Non-DOT - Collection Only (Company Chain of Custody)
WHS DOT Drug Screen (Work Health Solutions Chain of Custody)
DOT- Collection Only (Company Chain of Custody)
WHS Hair Test (5 panel) - (Work Health Solutions Chain of Custody)
Hair Collection Only (Company Chain of Custody)
Breath Alcohol Testing - NON - DOT
Breath Alcohol Testing - DOT
Drug Screen Observation/Witness Collection:
Yes
No
Reason for Testing:
(Required)
Pre-Placement / Employment / New Hire
Post Accident
Random
Reasonable Suspicion/Cause
Return to Duty
Follow-Up
Other (Specify)
DOT Agency
(Required)
FMCSA
FAA
FRA
FTA
PHMSA
USCG
DOT Agency
(Required)
FMCSA
FAA
FRA
FTA
PHMSA
USCG
DISA: If DISA is your TPA and you require a DISA test, please mark the section below.
Pre-Placement
Random
Post - Accident
Hair
Urine (Non - DOT)
Urine (DOT)
BAT (Non-DOT)
BAT (DOT)
DOT Agency
(Required)
FMCSA
FAA
FRA
FTA
PHMSA
USCG
DOT Agency
(Required)
FMCSA
FAA
FRA
FTA
PHMSA
USCG
Respiratory Services: Please ensure employee meets the OSHA standard for fit testing procedures. The test shall not be conducted if there is any hair growth between the skin and the facepiece sealing surface such as stubble beard growth, beard, mustache or sideburns which cross the respirator sealing surface.
Fit Testing - Quantitative (Quantifit2)
Fit Testing - Qualitative (Taste Test)
Pulmonary Function Testing (PFT)
OSHA Questionnaire
Masks:
(Required)
3M Half Facepiece 6000 series
3M Half Facepiece 7000 series
MSA Half Facepiece
3M Full Facepiece Respirator
Scotts Full Facepiece Respirator AV 2000
Scotts Full Facepiece Respirator AV 3000
North™ Series Full-Facepiece Respirator
Other
If other, please specify:
(Required)
Masks:
(Required)
3M Half Facepiece 6000 series
3M Half Facepiece 7000 series
MSA Half Facepiece
N95/KN95
Other
If other, please specify:
(Required)
Audiometric Testing:
Baseline
Retest
Make-Up Test
Annual Test
Vision Testing:
Titmus (Near, Distant and Peripheral)
Ishihara (Color)
Jaegar (Near Vision Acuity)
Peripheral
Snellen (Distant Vision)
Tumbling "E" Vision Test
Additional Services:
TB Skin Test (Employee must be able to return to the clinic within 48 to 72 hours to have test read)
Heplisav B Injection
2 View L-Spine Xray
Platinum Sensitivity Testing
Laboratory Tests (Please be specific):
Other Requirements (Please be specific):
Authorized Signature (Please Type Full Name)
(Required)
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