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1714 Charlestown New Albany Rd, Jeffersonville, IN 47130

OMP Authorization for Services

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Phone

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Employee's Name*

Birthdate*

Phone*

Company Name*

Expiration Date*

Authorized By*

Phone*

DRUG/ALCOHOL SCREENING SERVICES

Type of Test:

DOT

Non-DOT

Instant

Breath Alcohol

Other

Other Test Type

Reason for Test:

Random

Pre-employment

Post-accident

Reasonable Cause

Return-to-Duty

Other

Other Reason

VACCINATIONS

Vaccinations

Influenza (Flu)

COVID-19

Tdap

Hepatitis B

Other

PHYSICAL EXAM

Physical Exam

Pre-employment Exam

Return-to-Work / Fitness for Duty

DOT Certification

OSHA Respirator Medical Evaluation

Other

Other Physical Exam

TB TESTING

TB Testing

PPD Skin Test

Quantiferon Gold Blood Test

INJURY TREATMENT

Date/Time of Injury

OTHER SERVICES

Other Services

Respirator Fit Test

Hearing Screening (Audiogram)

Vision Screening

Other

Other Services

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