Form simplifies report to employer on evaluation

A worksheet used by an occupational health provider in North Carolina may streamline much of the paperwork required to screen workers for certain hazards, while also ensuring that you perform all the required examinations for any particular client’s employees.

The Provider’s Written Opinion Report of Medical Evaluation is a form used by Ada Fisher, MD, MPH, chief of occupational health services at the Veterans Affairs (VA) Medical Center in Salisbury, NC. She and her colleagues developed the form in private industry in 1990, and Fisher adopted the form for the VA center in 1997.

The components of the form are aimed at the issues of concern to VA employees, but Fisher says any occupational health program in private industry could modify the form easily. (See the form, pp. 19-20. Because the VA is a federal organization, no copyright permission is required for you to use or adapt the form.)

The form is intended for the occupational provider to use as a single report on an employee’s medical evaluation that covers all the possible exposures in that person’s workplace. For the VA center, that includes 18 exposures, from acetic acid and asbestos to tuberculosis and waste anesthetic gases. The occupational health provider can check off which of these work exposures applies to the worker being examined and then add the results of the examination.

"This one is my favorite form. With one form, you get over a dozen exams," Fisher says. "The charts get really thick really fast when you add a separate form for each exam, even if the results are all negative. With this one sheet of paper, you can answer all of these questions for all of these exposures all at once."

Form addresses OSHA-required questions

Fisher also notes that the single form could be helpful for providers with tight budgets for new forms. Rather than having to print a new form for each client, a single evaluation form can be printed with the most common workplace exposures, and the provider can check off the ones that apply.

If a single client is large enough or has significantly different exposures in the workplace, it might be worthwhile to print an evaluation form that is tailored to that one client. But even then, Fisher notes that you can put all of those client’s multiple exposures on a single form.

In addition to marking which exposures apply to the worker, the form also has four boxes that prompt the provider to provide information mandated by the federal Occupational Safety and Health Administration (OSHA).

"When you read the OSHA legislation, there are four basic questions that have to be answered for anybody," Fisher explains. Those questions are:

• Did you find any abnormalities in the exam?
• Do any of those put the worker at risk for the exposures in the workplace?
• Does the employee require restrictions?
• What are the recommendations for follow-up?

The form allows the provider to note that all of those findings were negative or to detail the findings and specify the follow-up dates.

To comply with OSHA regulations, the form includes a special warning that workers exposed to asbestos may increase their risk of lung cancer if they smoke. The back of the form provides instructions on how to use the form, as well an explanation of why the examinations were conducted.

The top copy of the form goes in the employee’s medical file kept in the occupational health department, and the second is given to the employee in compliance with OSHA standards. Those copies are identical. If the employee’s copy must be mailed, there is a box to indicate the date the form was mailed.

At the VA center, the third page is sent to the safety and industrial hygiene department, and the fourth page is sent to the employee’s supervisor or human resources. The filing of the third and fourth pages may vary according to your needs, but one should be sent to the supervisor or employer.

Fisher notes that the third and fourth pages do not contain all of the information on the first and second pages. The boxes pertaining to the employee’s examination abnormalities, medical conditions, and follow-up plans are blacked out because the employee’s supervisor should not be given that confidential information. The remainder of the form provides documentation that the employee was screened for certain exposures and explains any necessary restrictions.

(Editor’s note: Another form used by Fisher to improve return-to-work orders was featured in the January issue of Occupational Health Management, pp. 4-5.)


For more information on the form, contact:

Ada Fisher, Chief of Occupational Health Services, VAMC Salisbury, 1601 Brenner Ave., Salisbury, NC 28144. Telephone: (704) 638-9000.