![](media/image1.png) **TYPE OF PICTURE ID
CHECKED:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

  ------------------------------------------------------ -- ---------- --------- --
  **MRO Verification Progress Note Template 2004rev.**      **Script             
                                                            done**               

                                                                                 
  ------------------------------------------------------ -- ---------- --------- --

**Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Social Security #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Pass #:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_**

A)  **The employee presents for a (initial, follow up) visit:**

> **The reason for this visit is:**

  -- ----------------------------- -- ------------------- -- ------------- -- ---------------
     A positive drug test             A failure to           Specimen         Specimen
                                      complete a drug        substituted      adulterated
                                      test                                    

                                                                              

     Other                                                                    
     )\_\_\_\_\_\_\_\_\_\_\_\_\_                                              
  -- ----------------------------- -- ------------------- -- ------------- -- ---------------

> The date of testing was (\_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_).
>
> **The reason for the test was:**

  -- ---------------- -- ----------- -- -------- -- ----------- -- ------------------------------ -- -----
     Pre-employment      Periodic       Random      Post           For cause                         
                                                    accident                                         

                                                                                                     

     Return to work      Promotion      AWOL        Recheck        Other:                            
                                                                   \_\_\_\_\_\_\_\_\_\_\_\_\_\_      
  -- ---------------- -- ----------- -- -------- -- ----------- -- ------------------------------ -- -----

  ----------- -- ------------- -- --------- -------------------------------------------------
  **This test    **Non-DOT**      **DOT**   **The specimen ID number:**
  was a**                                   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

  ----------- -- ------------- -- --------- -------------------------------------------------

> **The result of the test is positive for:**

  -- -------------------------------- -- -------------- -- ----------------- -- ---------- -- -------------------------------------- ------ -- ----------- --------
     Amphetamines                        Barbiturates      Benzodiazepines      Cocaine       Marijuana                                        Methadone   

                                                                                                                                                           

     Opiates/codeine/morphine/6-MAM                        Phencyclidine        Dilantin      Other:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                         
  -- -------------------------------- -- -------------- -- ----------------- -- ---------- -- -------------------------------------- ------ -- ----------- --------

> **Current History:**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **Current medications include:**
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **Other substances used, eaten, administered include:**
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **Past medical history is significant for:**
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B)  **Physical exam:** Blood Pressure: \_\_\_\_\_\_/\_\_\_\_\_, Pulse:
    \_\_\_\_\_, Temperature: \_\_\_\_\_\_\_, Respiration:
    \_\_\_\_\_\_\_\_

  ------------- -- ------------------------------------------ -- ------------ -- --------- ---- -- ------- -- ------ -- ---------- --------
  Appearance:      Well dress                                    Disheveled      Unkempt           Clean      Neat      Poor       
                                                                                                                        hygiene    

                                                                                                                                   

                   Other:                                                                                                          
                   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                        
  ------------- -- ------------------------------------------ -- ------------ -- --------- ---- -- ------- -- ------ -- ---------- --------

  ---------- -- -------- -- ------------ -- ----------- -- ------------ -- ---------- -------------
  HEENT:        Normal      Induration      Vascular       Turbinate       Blue color 
                                            edema          swelling        erythema   

                                                                                      

  Abdomen:      Normal                                                                
  ---------- -- -------- -- ------------ -- ----------- -- ------------ -- ---------- -------------

> (Liver size \_\_\_\_\_\_\_cm, shape: \_\_\_\_\_\_\_\_, Texture:
> \_\_\_\_\_\_\_, Venous malformations: \_\_\_\_\_\_\_\_\_\_, Fluid
> levels:\_\_\_\_\_\_\_\_)
>
> **Extremities:**

  -------- -- -------- -- ------------------------- -------- -- ------------ -- ------ -- ----- -- --------- -- -------- ---- ----
  Skin:       Normal                                Clammy      Decreased       Pale      Red      Icteric      Poor          
                                                                turgor                                          venous        
                                                                                                                return        

                                                                                                                              

  Track                   Upper Extremities: Neck                                                                             
  marks:                  \_\_\_\_\_\_\_\_\_ Chest:                                                                           
                          \_\_\_\_\_\_\_\_\_\_                                                                                

                                                                                                                              

                          Lower Extremities:                                                                                  
                          Abdomen:                                                                                            
                          \_\_\_\_\_\_\_\_\_\_                                                                                
                          Groin:                                                                                              
                          \_\_\_\_\_\_\_\_\_\_\_.                                                                             
  -------- -- -------- -- ------------------------- -------- -- ------------ -- ------ -- ----- -- --------- -- -------- ---- ----

> Other lesions:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Neurological examination:

  ------------- -- ------------ -- --------- -- --------- -- ------------ ----- -- --------- -- -- --- -- --- -- -----------
                                                                                                                 

  **Speech:**      Articulate      Slurred      Garbled      Incoherent                                          
  ------------- -- ------------ -- --------- -- --------- -- ------------ ----- -- --------- -- -- --- -- --- -- -----------

  ------------------- -- -------- -- ---------- -- ----------------- -- ---------------------
  **Coordination:**      Normal      Impaired      Decreased finger     Impaired tandem
                                                   to nose              walking

  ------------------- -- -------- -- ---------- -- ----------------- -- ---------------------

  ----------- -- ---------------------------------------------------------------------------------- -- -- ----------------- -- ---------------- -----
                 Positive Romberg                                                                         Negative Romberg     Increased deep   
                                                                                                                               tendon reflexes  

                                                                                                                                                

                 Decreased deep tendon reflexes                                                                                                 
                 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                               
  ----------- -- ---------------------------------------------------------------------------------- -- -- ----------------- -- ---------------- -----

  ------------ -- --------------------------------------------------------
                  Nystagmus: absent \_\_\_\_\_\_\_ lateral ­­­­\_\_\_\_\_\_
                  horizontal \_\_\_\_\_\_\_\_, rotatory ­­­\_\_\_\_\_\_\_

  ------------ -- --------------------------------------------------------

> **Mental Status:** Orientation (date, place, person, none). Alertness:
> Yes\_\_\_ No\_\_\_
>
> Memory:
> \_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

C)  **Assessment:**

> **1. Verified Positive for:**

  -- -------------------------------- -- -------------- -- ----------------- -- -- ---------- -- ------------------------------------ ------ -- ----------- --------
     Amphetamines                        Barbiturates      Benzodiazepines         Cocaine       Marijuana                                      Methadone   

                                                                                                                                                            

     Opiates/codeine/morphine/6-MAM                        Phencyclidine           Dilantin      Other:\_\_\_\_\_\_\_\_\_\_\_\_\_\_                         
  -- -------------------------------- -- -------------- -- ----------------- -- -- ---------- -- ------------------------------------ ------ -- ----------- --------

> **2. Verified Negative for:**

  -- -------------------------------- -- -------------- -- ----------------- -- -- ---------- -- ------------------------------------ ------ -- ----------- --------
     Amphetamines                        Barbiturates      Benzodiazepines         Cocaine       Marijuana                                      Methadone   

                                                                                                                                                            

     Opiates/codeine/morphine/6-MAM                        Phencyclidine           Dilantin      Other:\_\_\_\_\_\_\_\_\_\_\_\_\_\_                         
  -- -------------------------------- -- -------------- -- ----------------- -- -- ---------- -- ------------------------------------ ------ -- ----------- --------

  -------------- -- ----------------- -- --------------- -- -----------------
  **3. Test         Specimen             Specimen           Specimen
  cancelled:**      inconclusive         substituted        adulterated

  -------------- -- ----------------- -- --------------- -- -----------------

  ---------------- -- ---------------- -- --------------- -- -----------------
  **4. Test not       Specimen            Specimen           Specimen
  performed:**        inconclusive        substituted        adulterated

  ---------------- -- ---------------- -- --------------- -- -----------------

  -- ---------------------------- --------------------------------- ------------
     **For specimen adulterated                                     **Found.**
     presence of**                                                  

  -- ---------------------------- --------------------------------- ------------

  ------------ -- -------------- -- -----------------------------------------------
  **5.            **Not             **No medical reason found to explain inability
  Refusal:**      applicable**      to give a valid urine test.**

                                    
  ------------ -- -------------- -- -----------------------------------------------

D)  **Assessment:**

  ------------- -- -------- -- ------------ -- ------- -- ----------- -- -----------
  **1. Work        Full        Restricted      No Work    Permanent      Temporary
  Status:**        Work        Work                                      

  ------------- -- -------- -- ------------ -- ------- -- ----------- -- -----------

  ------------- -- -------------------------------------------------------
  **2. Urine       Yes on **\_\_\_\_\_/\_\_\_\_/\_\_\_\_ for reason (1, 2,
  retest:**        3, 4, 5, 6A, 6B, 6E, 6F, other)**

  ------------- -- -------------------------------------------------------

  -- -- ---- -- --------------- -- ------------------ -- ------------------------
        No      Continue with      Positive for          Pending receipt of
                medication         illegal substances    further documentation.

  -- -- ---- -- --------------- -- ------------------ -- ------------------------

  ---------- -- ------------------------------ -- --------------------------
  **3. Refer    Designated Employee               Psychological Services
  to:**         Representative (DER)              

  ---------- -- ------------------------------ -- --------------------------

> **4. Return visit on \_\_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_ to MAC (1,
> 3, 5) at \_\_\_\_\_: \_\_\_\_\_\_.**

  -------- -- ------------------- -- ------------------------------ -- ----------------
  **5.**      **DOT confirmation     **Yes, Laboratory requested       **No**
              requested:**           \_\_\_\_\_\_\_\_\_\_\_\_\_**      

  -------- -- ------------------- -- ------------------------------ -- ----------------

  ---- -- ---------------------- -- ----------------------------------------
                                    **Deferred until
                                    \_\_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_, time
                                    \_\_\_\_\_:\_\_\_\_\_**

  ---- -- ---------------------- -- ----------------------------------------

E)  Comments:

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  **Signature of MRO**                                                  
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