**[Fitness-for-duty Physical Examination]{.smallcaps}**

**[Prescription, Over-the-county, and Dietary Supplement Disclosure
Form]{.smallcaps}**

# Instructions for employees in safety-sensitive positions

All employees required to have a biannual fitness-for-duty physical
examination must complete this form and present it for review and
assessment by a qualified medical practitioner designated (approved) by
your employer.

The \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ transit
system is dedicated to providing a safe efficient working environment
free from the harmful effects of substance abuse or misuse. The use of
prescription drugs, over-the-counter medications, and dietary
supplements may impact your ability to perform your job duties in a safe
and competent manner. As part of the transit system's biannual
fitness-for-duty evaluation, you are required to disclose the use of
these substances. The physician will determine whether any of these
substances singularly or in combination can be safely used while
performing safety-sensitive duties.

1)  Complete Part I-V of the form in its entirety. Be sure to list all
    prescription drugs, over-the-counter medications, and dietary
    supplements that you use on an ongoing or periodic basis, or that
    you intend to use. Be thorough. Obtaining advance approval through
    this review may minimize delays in future fitness-for-duty
    assessments.

2)  Have the employer designated / approved physician complete Part VI
    of this form to complete this portion of your fitness-for-duty
    evaluation.

3)  Return completed form to your employer.

**[Part I. Employee Safety-sensitive Job Duties]{.smallcaps}**

**[(to be completed by employee)]{.smallcaps}**

I perform the following safety-sensitive job duties (check all that
apply):

> Operate a transit bus, paratransit vehicle, or sedan that carries
> large numbers of the riding public including the elderly, the
> disabled, and the young.

Operate vehicles on a fixed-guideway including trains, trolleys, etc.

Operate a vehicle requiring a commercial driver's license (CDL)

Control the dispatch or movement of transit vehicles

Maintain / repair transit vehicles

Carry a firearm for security purposes

**[Part II. Employee Prescription Medication Disclosure]{.smallcaps}**

A\) I take the following prescriptions on an ongoing or periodic basis:

Name of Medication:

Dosage:

Directions:

Duration of Use:

Expiration Date:

Number of Refills:

Prescribing Physician:

List any side effects:

Name of Medication:

Dosage:

Directions:

Duration of Use:

Expiration Date:

Number of Refills:

Prescribing Physician:

List any side effects:

Name of Medication:

Dosage:

Directions:

Duration of Use:

Expiration Date:

Number of Refills:

Prescribing Physician:

List any side effects:

Name of Medication:

Dosage:

Directions:

Duration of Use:

Expiration Date:

Number of Refills:

Prescribing Physician:

List any side effects:

Name of Medication:

Dosage:

Directions:

Duration of Use:

Expiration Date:

Number of Refills:

Prescribing Physician:

List any side effects:

B\) I may take the following prescriptions as the need arises:

Pain Relief:

Antibiotic:

Sinus/Allergy Relief:

Anti-inflammatory:

Other:

**[Part III. Employee Over-the-counter Medication
Disclosure]{.smallcaps}**

A\) I take the following over-the-counter medications on an ongoing or
periodic basis:

Name of Medication:

Dosage:

Directions:

Frequency of Use:

Name of Medication:

Dosage:

Directions:

Frequency of Use:

Name of Medication:

Dosage:

Directions:

Frequency of Use:

Name of Medication:

Dosage:

Directions:

Frequency of Use:

Name of Medication:

Dosage:

Directions:

Frequency of Use:

B\) I may take the following over-the-counter medications as the need
arises:

Pain Relief:

Sinus/Allergy Relief:

Cold/Flu Medication:

Other:

**[Part IV. Employee Dietary Supplement Disclosure]{.smallcaps}**

A\) I take the following dietary supplements/herbal remedies on an
ongoing or periodic basis:

Name of Supplement/Remedy:

Amount:

Frequency of Use:

List any side effects:

Name of Supplement/Remedy:

Amount:

Frequency of Use:

List any side effects:

Name of Supplement/Remedy:

Amount:

Frequency of Use:

List any side effects:

Name of Supplement/Remedy:

Amount:

Frequency of Use:

List any side effects:

Name of Supplement/Remedy:

Amount:

Frequency of Use:

List any side effects:

I hereby authorize my medical practitioner,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, to release the
information requested on this form. I understand that it is my
obligation to inform my employer of any prescription or over-the-counter
medication I am taking or intend to take for review and determination of
my fitness for duty as part of my periodic physical examination. I also
understand that I must report my intended use of any prescription drug,
over-the-counter drug, or dietary supplement that were not reported
during my physical examination to my employer on an information
disclosure form. I understand that this information may be reviewed by a
medical practitioner to determine my fitness for duty. The information
that is presented on this form is current and correct to the best of my
knowledge. I understand and will comply with the prescribed use of these
medications/supplements and their restrictions while performing
safety-sensitive duties.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee's Signature Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee's Printed Name

**[Part V. Physician Completes This Section]{.smallcaps}**

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
am aware of the safety-sensitive job duties of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who is
a/an \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ at the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. I have
reviewed the employee's medical history, current physical condition, and
use or intended use of the prescription drugs, over-the-counter
medications, and dietary supplements listed in Sections II -- IV of this
form. It is my opinion that:

> If the disclosed prescriptions, over-the-counter medications, and
> dietary supplements are taken in accordance with the above directions,
> the substances (individually or in combination) should not naturally
> impair the employee's ability to perform his/her job competently and
> pose no threat to public safety.
>
> The employee should not perform safety-sensitive duties while taking
> the following prescription drugs, over-the-counter medications, and
> dietary supplements:
>
> The following restrictions should be placed on the employee while
> he/she is taking the indicated medications or supplements.
>
> Name of Medication / Supplement:
>
> Restriction:
>
> Name of Medication / Supplement:
>
> Restriction:
>
> Name of Medication / Supplement:
>
> Restriction:

Other, please specify:

Signed: Date:

Please print the following:

> Name:
>
> Address:
>
> Phone Number:

**[Medical Approval Form]{.smallcaps}**

Employee Name: Date:

ID #: Job Title:

As the prescribing physician, I have prescribed the following
medications:

Name of Medication:

Dosage:

Strength:

Duration of Use:

Name of Medication:

Dosage:

Strength:

Duration of Use:

Name of Medication:

Dosage:

Strength:

Duration of Use:

Name of Medication:

Dosage:

Strength:

Duration of Use:

Name of Medication:

Dosage:

Strength:

Duration of Use:

Please check one of the following:

> The employee may perform safety-sensitive duties while taking this
> medication.
>
> The employee may perform safety-sensitive duties while taking this
> medication, as long as the following restrictions are met and
> instructions followed:
>
> The employee may not perform safety-sensitive duties while taking this
> medication. Provide additional explanation, as necessary.

By signing below, I acknowledge that I am aware of the employee's job
requirements and day-to-day responsibilities, and that the
newly-prescribed drugs, in conjunction with the employee's physical
condition and medical history, will not impair performance or endanger
the safety of this individual, co-workers, transit passengers, or the
public.

Signed: Date:

Please print the following:

> Name:
>
> Address:
>
> Phone Number:

**[New Prescription Drug Disclosure Form]{.smallcaps}**

Employee Name: Date:

ID #: Job Title:

This form should be used to disclose any new prescription medication
that you are taking or intend to take that was not listed as part of
your last employer physical examination.

Name of Medication:

Dosage:

Directions:

Duration of Use:

Expiration Date:

Number of Refills:

Prescribing Physician:

List any side effects:

I understand that it is my obligation to inform my employer of any
medications/ supplements I am taking or intend to take for review and
determination of my fitness for duty. This information is true and
correct to the best of my knowledge. I understand and will comply with
the directed use of these medications/supplements and their restrictions
while performing safety-sensitive duties.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee's Signature Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee's Printed Name

**[Physician Completes This Section]{.smallcaps}**

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
am aware of the safety-sensitive job duties of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who is
a/an \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ at the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. I have
reviewed the employee's bi-annual physical examination containing the
employee's medical history, physical condition, and use or intended use
of the prescription drugs, over-the-counter medications, and dietary
supplements. It is my opinion that:

> If the disclosed prescription is taken in accordance with the above
> directions, the substance should not naturally impair the employee's
> ability to perform his/her job competently and pose no threat to
> public safety.
>
> The employee should not perform safety-sensitive duties while taking
> the above prescription drug.
>
> The following restrictions should be placed on the employee while
> he/she is taking the indicated medication:
>
> Restriction:

Signed: Date:

Please print the following:

> Name:
>
> Address:
>
> Phone Number:

**[New Over-the-counter Drug Disclosure Form]{.smallcaps}**

Employee Name: Date:

ID #: Job Title:

This form should be used to disclose any new over-the-counter medication
that you are taking or intend to take that was not listed as part of
your last employer physical examination.

Name of Medication:

Dosage:

Directions:

Duration of Use:

Expiration Date:

List any side effects:

I understand that it is my obligation to inform my employer of any
medications/ supplements I am taking or intend to take for review and
determination of my fitness for duty. This information is true and
correct to the best of my knowledge. I understand and will comply with
the directed use of these medications/supplements and their restrictions
while performing safety-sensitive duties.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee's Signature Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee's Printed Name

**[Physician Completes This Section]{.smallcaps}**

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
am aware of the safety-sensitive job duties of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who is
a/an \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ at the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. I have
reviewed the employee's bi-annual physical examination containing the
employee's medical history, physical condition, and use or intended use
of the prescription drugs, over-the-counter medications, and dietary
supplements. It is my opinion that:

> If the disclosed over-the-counter medication is taken in accordance
> with the above directions, the substance should not naturally impair
> the employee's ability to perform his/her job competently and pose no
> threat to public safety.
>
> The employee should not perform safety-sensitive duties while taking
> the above over-the-counter medication.
>
> The following restrictions should be placed on the employee while
> he/she is taking the indicated medication:
>
> Restriction:

Signed: Date:

Please print the following:

> Name:
>
> Address:
>
> Phone Number:

**[New Dietary Supplement Disclosure Form]{.smallcaps}**

Employee Name: Date:

ID #: Job Title:

This form should be used to disclose any new dietary supplement that you
are taking or intend to take that was not listed as part of your last
employer physical examination.

Name of Medication:

Dosage:

Directions:

Duration of Use:

List any side effects:

I understand that it is my obligation to inform my employer of any
medications/ supplements I am taking or intend to take for review and
determination of my fitness for duty. This information is true and
correct to the best of my knowledge. I understand and will comply with
the directed use of these medications/supplements and their restrictions
while performing safety-sensitive duties.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee's Signature Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee's Printed Name

**[Physician Completes This Section]{.smallcaps}**

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
am aware of the safety-sensitive job duties of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who is
a/an \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ at the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. I have
reviewed the employee's bi-annual physical examination containing the
employee's medical history, physical condition, and use or intended use
of the prescription drugs, over-the-counter medications, and dietary
supplements. It is my opinion that:

> If the disclosed dietary supplement is taken in accordance with the
> above directions, the substance should not naturally impair the
> employee's ability to perform his/her job competently and pose no
> threat to public safety.
>
> The employee should not perform safety-sensitive duties while taking
> the above dietary supplement.
>
> The following restrictions should be placed on the employee while
> he/she is taking the indicated dietary supplement:
>
> Restriction:

Signed: Date:

Please print the following:

> Name:
>
> Address:
>
> Phone Number: