First Aid/Medical Facilities

Content

SUMMARY
Content........................................................................................................................................................................................... 1

5.1 Site First Aid/Medical Facilities............................................................................................................... 3

5.2 Purpose............................................................................................................................................................. 3

5.3 Scope.................................................................................................................................................................. 3

5.4 Minimum Requirements............................................................................................................................. 3

5.5 General.............................................................................................................................................................. 3
5.5.1 Responsibilities................................................................................................................................................................. 3
5.5.2 Definitions........................................................................................................................................................................... 4
5.5.3 Procedure............................................................................................................................................................................ 4
5.5.3.1 Duties of the Nurse.............................................................................................................................................5
5.5.3.2 Medical Procedure..............................................................................................................................................5
5.5.4 Medical Facility................................................................................................................................................................ 7

REFERENCES........................................................................................................................................................... 7
APPENDICES........................................................................................................................................................................ 7

Appendix A............................................................................................................................................................ 8
List of Information Sources/Duties of the Nurse.................................................................................................... 8

Appendix B............................................................................................................................................................ 9
GdC First Aid Log...................................................................................................................................................................... 9
Sample First Aid Sign-In Sheet...................................................................................................................................... 10
Sample First Aid Equipment & Supplies.................................................................................................................... 11
Office Furniture/Equipment..............................................................................................................................11
Miscellaneous Supplies........................................................................................................................................ 11
First Aid Kits:................................................................................................................................................................ 12

Appendix C......................................................................................................................................................... 14
Injured Worker Case Management and Return-To-Work Forms................................................................14
Injured Worker Information..................................................................................................................................... 14
Return to Work Authorization..................................................................................................................................15
Medical Progress Notes............................................................................................................................................... 16
 Medical Records (a)...................................................................................................................................................... 17
Medical Records (b)...................................................................................................................................................... 17
Medical Records (c).......................................................................................................................................................18
Medical Records (d)...................................................................................................................................................... 20
Medical Records (e)...................................................................................................................................................... 21
Physician’s Release........................................................................................................................................................22

Appendix D......................................................................................................................................................... 23
Employee Personal Health File....................................................................................................................................... 23

5.1 FIRST AID/MEDICAL FACILITIES

5.2 PURPOSE
Every Gas of Cameroon worksite must provide facilities for emergency first aid and medical
treatment for the care and treatment of workers who have incurred an occupational injury or
illness.

5.3 SCOPE
This procedure provides the requirements for the duties of the assigned medical staff who
operate the first aid facility (ies), render first aid, and maintain reports on our activities. (Of all)

5.4 MINIMUM REQUIREMENTS

At a minimum, every Gas of Cameroon worksite site must have the ability to:

( do you mean every Gas of Cameroon worksite nurse must have the ability to)

 Render first aid to victims of occupational injuries and illnesses.

 Provide follow-up remedial nursing care to first aid cases.
 Coordinate response to field emergencies with the First Aid and Rescue Teams according
to established site procedures.
 Prepare injury reports and maintain current and complete records and logs.
 Refer to the Occupational doctor, clinic, or hospital any cases that require more
attention than first aid care.
 Check workers returning to work after periods of absence due to injury or illness.
 Keep first aid equipment and supplies properly maintained, cleaned, and arranged
neatly.

5.5 GENERAL
5.5.1 RESPONSIBILITIES
 The QHSSE Manager is responsible for implementing and enforcing this procedure.
  The Registered Nurse, Licensed Practical Nurse, Paramedic, Emergency Medical
Technician, or Certified First Aid Attendant must render first aid and maintain accurate
records.
 The company Doctor needs to ensure legal compliance and oversee the technical
operations of the nursery (nurses) reporting to the QHSSE Manager
 The QHSSE Manager must supervise the operation of the first aid facility and see to the
regulatory maintenance of the injury records and report to the Managing Director or
COO in case.

5.5.2 DEFINITIONS
First Aid Facility - The place or facilities where workers obtain first aid services.
Nurse - A registered industrial nurse or a licensed practical nurse. (In the absence of a
registered nurse or a licensed practical nurse, the emergency medical technician [EMT],
paramedic, or first aid attendant must assume the responsibilities outlined in this
procedure.)
Company Medical Advisor - The licensed physician selected by GDC to serve as the medical
consultant for the company who must issue Standing Orders to company nurses. Cases
requiring more than first aid care must be referred to the Company Medical Advisor.
Standing Orders - Written instructions for handling first aid cases issued by the Medical Advisor
issued for the nurse to follow. These must be reviewed at least once per year.

5.5.3 PROCEDURE
The registered nurse licensed practical nurse, paramedic, or certified first aid attendant must
have the duty of rendering first aid to victims of occupational injuries or illnesses contracted
while at work and in the performance of assigned duties related to GDC activities.
The first aid staff must perform duties and responsibilities according to established
requirements. In addition, a volunteer trained first aid team must be available to render first aid
care promptly at the scene of the accident and whenever necessary.
The administration of the first aid facilities and operations is under the supervision of the
QHSSE Manager.
A physician has been selected by GDC management to provide medical treatment as the need
arises, refer patients to specialist physicians when the need exists, and act as medical advisor
to the GdC.

A selection of the available physician was based on prior experience in the area, and contacts
with GdC, other employers, and consideration of his knowledge of the legal medical
Environment of Cameroon, Workers' Compensation insurance underwriters. Regular meetings
are held with the doctor, preferably at the jobsite, to overview the Health and Safety program
and the GdC’s QHSSE philosophy for the prevention of accidents. Discussions on these meetings
are subject to approval by the QHSSE Manager.

Hospitals and clinics have been chosen to handle emergency cases. A conference with hospital
administrators will be scheduled at which time arrangements must be developed for the
coordination of GdC and hospital efforts for the medical treatment of workers who become
injured or ill in the course of employment. A hospital's capabilities are to be ascertained and
their facilities visited. Hospital authorities must be requested to give advice regarding
ambulance and doctor services in the area, which would best serve GDC's needs.
Arrangements will be made for use of local ambulance services and, if required, helicopter
services.

A survey must be made to determine what ambulance service is available to the jobsite. Its
capability, proximity and time required to meet emergency calls at different times of the day are
important. Laws regulating emergency medical services must be fully reviewed . If ambulance
service is more than approximately 20 minutes away, an ambulance for the jobsite must be
considered. If an ambulance is maintained on the jobsite, ambulance drivers and their
alternates must be located at the jobsite.

Available private and military life support helicopter service must be investigated. Contacts must
be made to establish the necessary steps to implement emergency service, if the need arises.

The QHSSE Manager must be responsible for the verification of the current certification and
qualifications of the medical and first aid personnel through local registries, licenses, and
institutions.
When the above personnel are selected and assigned, they must be given clear instructions as
to their duties and functions regarding the treatment of injured and ill workers (See Duties of
the Nurse).

5.5.3.1 DUTIES OF THE NURSE

The prime function of the nurse is to provide first aid care for the GDC workers. The industrial
nurse makes a valuable contribution to the QHSSE program over and above the prime function
of rendering first aid for occupational injuries and illnesses by relaying causes of accidents and
any health or safety trends to the QHSSE Manager.
The nurse must work under the functional supervision of the QHSSE Manager, and the GDC
Medical Advisor must issue Standing Orders and technical assistance to the nurse.
Can the actual approved job description of the nurse be added in this document?

5.5.3.2 MEDICAL PROCEDURE

5.5.3.2.1Treatment of Individuals
All first aid care must be performed in a thorough and professional manner. Individuals who
need treatment beyond normal first aid care must be sent to a physician.
 Individuals who request treatment for personal injury or illness from incidents that did
not arise in the course of their employment on the GDC must not be treated in the GDC
first aid facility but must be referred to their personal physicians.
(This point needs to be reconsidered, because if we want to avoid people going out so
often just for a minor problem that can be managed temporarily, prior to the person to
see his physician. We need to review certain restrictions.
 The QHSSE Manager must be consulted to determine questionable cases, such as
emergencies outside the gate, required redressing, or checking blood pressure.
 Contractors are responsible for the treatment of their workers. If they desire to have
their workers use first aid facilities, special arrangements must be made, including the
signing of a hold harmless indemnification agreement prior to any first aid treatment
being rendered.
 5.5.3.2.2 Dispensing of Medication
The only medication that must be given to workers on the GDC through the first aid facility
must be ordered and approved by GDC Company Doctor and delegation of labour.
Medication such as aspirin, ointments, or solutions of medicines must be
prescribed only to the individual in need.
Medications such as cold tablets, decongestants, lotions, antacids, etc., must not be
dispensed, however they can be made available.

5.5.3.2.3 Medical Record Administration

Adequate records of all reported injuries and illnesses must be maintained by the individual
performing treatment or giving advice. The time, date, nature, extent, and cause of injury
or illness must be documented on the established reporting forms. This includes both job
related cases and reported personal conditions. It is mandatory that precise information be
obtained in each reported case.
All medical records must be considered confidential and must not be seen or reviewed by
unauthorized personnel. Anyone other than authorized personnel wishing to see or review
medical records must obtain permission through the QHSSE Manager and the worker(s).
Medical records, injuries, or illness cases must not be discussed over the telephone. It is
permissible to verify knowledge of injury or illness to doctors, hospitals, or worker
representatives, but the extent or cause of such injury of illness, as well as any related
information, must not be released on the telephone.
The following guidelines must be adhered to in the conduct of the daily first aid facility
activities:
The first aid facility and all first aid equipment must be kept clean and arranged neatly.
Unauthorized personnel must not be allowed to loiter in the first aid station. This facility is
strictly for first aid business.
All personnel requiring treatment must be required to remain in the treatment room
until treatment is completed.
 The first aid telephone must be used for company business only. Unauthorized
individuals must not use this telephone.
 The first aid vehicle or ambulance must be used for the purpose of transporting
individuals who require medical treatment beyond that which can be received in the first
aid facility. Except for vehicle maintenance of very short duration, it must not leave the
premises.
 The QHSSE Manager is to be contacted immediately in the event of any serious or
questionable injury reported to the first aid station. The Contractor’s Safety Manager
must also be advised of frequent visits by the same individual and must inform
management of the case.

5.5.3.2.4 Records
First aid records are not only confidential, but also are most important in assisting the accident
prevention activities on the job. The nurse or first aid attendant must maintain records in
confidential files as necessary. A number of sample forms are provided in the Appendices for:
 GDC First Aid Log; Sample First Aid Sign-In Sheet; Sample First Aid Equipment &
Supplies; Medical Unit Diagram (Appendix A),
 Injured Worker Case Management and Return-To-Work Forms ( B)
  Worker Personal Health File (Appendix C)
 Employer’s First Report of Injury / Illness (Workers Compensation Cases in the US -See
Country & States Requirements, Appendix D)
 Please sir I would like to draw your attention on the fact that there are 03 different logs
or registers certified and issued to us by the delegation of labour:
 Work related cases or accidents and occupational health diseases.
 Daily consultation registers for not work-related cases.
 Health risk assessment log.
I would like to find out if it is important to mention in this document the role and
importance of these 3 logs.

5.5.3.2.5 Medical Form Control

All blank forms used to document the information related to an injury or illness at GdC must be
stored and controlled to prevent access by unauthorized personnel. They must not be left out
unattended.
5.5.3.2.6 Records Retention
All medical and injury records and related documents must be sent to the head office for
retention.
All OSHA records must be retained for 5 years after the job closeout.

All health hazard exposure records must be retained for 30 years after the job closeout.
5.5.3.2.7 Access
OSHA's Recordkeeping requirements permit OSHA and worker access to OSHA Form 300.
This rule allows any worker, former worker, or their representative(s) to examine and copy
the OSHA Log and Summary in a reasonable manner and at reasonable times.

5.5.4 MEDICAL FACILITY

The proper size of a facility depends on the number of employee on site, the frequency and
type of accidents, and the hazards created by the work performed. The following guide is a
good scale to assist in the planning of the first aid facility. Local regulations are often
prescriptive.
Up to 200 employees, 175 square feet
500 - 1,000 employees, 300 square feet, or 1square foot per employee.
For more than 1,000 employees, less that 1square foot per employee may be needed.
The First Aid Facility should be operated in the same atmosphere that exits in a hospital
and a physician's private office. The facility should enable medical personnel to function
professionally, and should be readily accessible for all employees, including handicapped
personnel, and emergency transportation. The facility may contain either a direct telephone
line, or a two way radio connected to a radio dispatcher.

REFERENCES
 Cameroon Labour Code Law N° 92/007 of 14 August 1992 Chapter II Health Services
 Order number 015 of October 1979 related to the organisation of Health Services at
work
 Employee Medical Advisory Services (UK- EMAS)
  Title 29, Code of Federal Regulations, Parts 1910 and 1926, Occupational Safety and
Health Administration (OSHA), U.S. Department of Labour.
 GDC Standing Orders are issued by the GDC Medical Advisor and outline the procedures
to be followed by the nurse and/or first aid attendant in rendering first aid.

APPENDICES
 Appendix A, List of Information Sources/Duties of the Nurse
 Appendix B, GDC First Aid Log; Sample Sign-In Sheet; Sample First Aid Equipment &
Supplies.
 Appendix C, Injured Worker Case Management and Return-To-Work Forms
 Appendix D, Worker Personal Health File

APPENDIX A
LIST OF INFORMATION SOURCES/DUTIES OF THE NURSE
1. Occupational Health Guide for Medical and Nursing Personnel, State Medical Society of
Wisconsin, 330 East Lakeside Street, Madison, WI 53701. Standing Orders sample.

2. Record Keeping Requirements, Occupational Safety and Health Administration.

3. MERC Manual, MERC Chemical Co., New York, NY.

4. Emergency Care and Transportation of the Sick and Injured - Committee on Injuries,
American Academy of Orthopaedic Surgeons, George Banta Co., Menasha, WI.

5. Dangerous Properties of Industrial Materials, Sax, N.J., R.H. Rheinhold, New York, NY.

6. Occupational Diseases - A Guide to Their Recognition. U.S. Government Printing Office,

Public Health Service Publication No. 1097, Washington, DC 20402.

7. Analysis of Workers' Compensation Laws, Chamber of Commerce of the United States,

Washington, DC Published annually.

8. A Guide for Services for Construction. American Medical Association, Department of

Occupational Health, 535 North Dearborn Street, Chicago, IL 60610.
9. Guide to Developing Industrial Disaster Medical Services. American Medical Association,
Department of Occupational Health, 535 North Dearborn Street, Chicago, IL 60610.
10. Taber's Cyclopaedia Medical Dictionary, F.A. Davis Company, Philadelphia, PA.
APPENDIX B
GDC FIRST AID LOG

1. All injuries no matter how slight must be entered in the GdC First Aid Log and a Work-
Related Injuries/Illness Form must be filled out. An employee must be given a release to
go back to work in full or part and a medical case file must be started on each employee.

2. The following information must be included when recording an injury or illness:

Date and time injury/illness occurred.

Date and time injury/illness was reported.
Name and badge number of patient
Occupation of patient
Type of injury or illness
(Example: Superficial laceration, right middle finger, medial phalanx)

Description of incident/accident
(Example: Labourer fell on scrap lumber and cut finger on nail)

Explanation of first aid treatment rendered.

(Example: Wound cleansed, antiseptic and bandage applied)

Medical attendant's initials

Where employee was sent back to work or to a doctor, hospital, or clinic.
What treatment was ordered for the employee by the doctor?
(Example: X-ray of left forearm, with wet reading)
3. All visitors to the first aid facility must be recorded in the GDC First Aid Log.

4. Any information concerning the physical health of an employee must not be entered in the
GDC First Aid Log. Physical health information must only be entered in the Employee's
personal health file, which must be in a secured location.

Example: Any old injuries, illnesses (diabetes, hypertension), existing conditions (back
problems, hernias), or significant operations.

5. A separate first aid log must exist for each contractor.

6. A separate file must be made for each employee who is listed on the first aid log. The
“Work Related Injury/Illness” Form, Return to Work Authorization form, copy of the
Incident Report and if the individual has been referred to the doctor a First Report of
Injury must be included in this file.
SAMPLE FIRST AID SIGN-IN SHEET

Date Employee Name Employee Signature Injury Comments

SAMPLE FIRST AID EQUIPMENT & SUPPLIES
OFFICE FURNITURE/EQUIPMENT
Desk Desk chair Desk lamp
File cabinets Computer with printer Computer table and chair
with locks
Two straight
back chairs
First Aid Furniture/Equipment
Treatment Hospital bed/cot Foot stool
chair
Examining Treatment table with drawers and Utility cart
lamp locks
Chrome 3 or 4 cubic feet refrigerator Supply cabinet and locks
revolving
stool
Bathroom- Self-closing waste can Clothes locker
toilet, basin,
and shower
Waste Telephone
basket
MISCELLANEOUS SUPPLIES
Stationery Office Supplies
and Report
Forms
First Aid Supplies
Aneroid Otoscope Set Pillow Cases – Disposable
Stethoscope Ring Cutter Thermometers and Sheaths
Junior Band Razor and Blades Fingernail drill and points
Aids
3/4" Band 1" Band Aids Set of Apothecary Jars
Aids
2" Band Aids 2 Qt. Basins (Round) 1" Dermicil Hypo-Allergenic Tape
Forceps Jar 1/2" Adhesive Tape Instrument Trays (Sterile and Unsterile
Instruments)
Thermomete 1" Adhesive Tape Knuckle Coverlets
r Jar
1 Qt. Bowl 2" Adhesive Tape Emesis Basins
Adhesive 2 x 2 Sterile Gauze Pads Fingertip Coverlets
Tape
Dispenser
Hot Water 3 x 3 Sterile Gauze Pads 3 x 3 Unsterile Gauze Pads
Bottle -
Disposables
Ice Bag - 4 x 4 Sterile Gauze Pads Water Sterilizer
Disposables
Ear Syringe 2 x 2 Unsterile Gauze Pads Medium Gauge 32 Oz.
4x4 Graduated Measure 2 x 2 Sterile Vaseline Dressings
Unsterile
Gauze Pads
Zephiran - Knife Handle and Blades 9 1/2" Forceps NAmmonia Inhalants
1:750
Anti-Rust Mosquito Forceps Dressing Forceps
Tablets
5" Tissue 5 1/2" Bandage Scissors Acetone
Forceps
Tweezers Visine Lysol
Hemostat Burn Ointment Blinx
(Small)
Crutches Forceps with teeth Vaseline
Traction int 2" Rubber Elastic Bandages Burn Spray

3" Rubber Merthiolate Caladryl

Elastic
Bandages
Alcohol 4 1/2" Kerlix 4" Rubber Elastic Bandages
2" Kling 3" Kling Icthammol - N.F.
1" Improved Campho Phenique Peroxide
Gauze
Band-Aid Salt Anbesol
Butterfly
Closures
Sterile Eye Q-Tips Ammonia
Patches
Chemical Cotton Balls Alcohol Swabs
Cold Packs
Blankets- Collyrium Eye Solution
Disposable

Tourniquets Chemical Heat Packs Neosporin Ointment

- Velcro
Lite Saver (Oropharyngeal) Gatorade or Kwick Kick
Tubes
Medicine Finger Cots Cutter Snake Bite Kit
Droppers
Tongue Flashlight or Penlight Pillows
Depressors
1 1/2" Sheets-Disposable Ocusol Eye Solution
Needles
(Sterile)
Aluminum Safety Pins Misc. Padded Wooden Splints
Finger
Splints
(Medium Cold Blanket Sterile H2O
and Large)
Surgical Polaris Dental Poultice CPR Chart
Scrub
Brushes
Sterile Second Skin Eye Chart
Sheets-
Burns
Plastic Foot Heimlich Maneuver Chart 2 Portable Oxygen Units
Tub
 FIRST AID KITS:
3 packages - 3 packages - Compress Bandage, 4" 3 packages - Compress Bandage, 2"
Adhesive pad, 1 per package pad, 4 per package
Bandages,
1" x 3" pad,
16 per
package

1 package - 1 package - Burn Ointment Tubes, 1 package - Wound Ointment Tubes,

Ammonia 0.11 oz., 6 per package 1/2 oz., 2 per package
Inhalants, 2 packages - Gauze Compress, 24" x 2 packages - Merthiolate, Swabs, 0.5
1/3 cc, 10 2 yards, 1 per package cc, 10 per package
per package
1 package -
Gauze
Bandage, 4"
x 6 yards, 1
per package

1 package - 1 package - Tourniquet and Forceps 2 pair - Sterile Gloves

Paper cups,
10 per
package

2 packages - 1 package - Wire Splint, 3 3/4" x 30", 1 Bottle - Eye Irrigating Solution
Triangular 1 per package
Bandage,
Nonsterile,
40", 1 per
package
. The above should be kept in
metal case; open lid serves shelf
 FIRST AID KIT INSPECTION CARD

Date Inspected Inspected by Items Needed

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.
APPENDIX C
INJURED WORKER CASE MANAGEMENT AND RETURN-TO-WORK FORMS

INJURED WORKER INFORMATION

Date of report:

Date & Time injury/illness occurred: Name of Working Partner:

Time in: Job title:_______________

Time out: Experience of Working Partner:

How long on this site:

Worker name:

SS# Subcontractor:

Date of hire: Foreman:

Supervisor:
Job title:

Experience:

How long on this site:

Work Location/Area:

Location of injury/illness:

Description of injury/illness:

Description of first aid administered:

Allergies:

Physician referral? ______ Yes or no

Return to work? ______ Yes or no

Tetanus up to date? ______ Yes or no

Restricted duty? ______ Yes or no

Recordable? ______ Yes or no

Workman’s comp? ______ Yes or no

Any related previous injury/illness? ______ Yes or no

If yes, describe:

Name of person/persons giving treatment:

Reviewed by:
 QHSSE Manager

RETURN TO WORK AUTHORIZATION

Date: _____________

Time: _____________

Date of injury: _______________

To: ________________________________ ( Supervisor)

___________________________________ was seen in the first aid office today for treatment
of

Treated by: ___________________________________

The employee is being released to return to work without restrictions .

Please sign and return to the QHSSE office.

____________________________________

Safety Supervisor

Superintendent

Foreman ___________________________

Worker

QHSSE Manager
MEDICAL PROGRESS NOTES

DATE NOTES & COMMENTS

MEDICAL RECORDS (A)
NOTICE to Employees – Job site

Employee medical records are maintained in the first aid office. A copy may be obtained by
filling in the request form available in the first aid office and then presenting this written
request to the QHSSE Manager A reasonable period of time will be required to fulfil the
request.

Manager/Supervisor

MEDICAL RECORDS (B)

RELEASE OF EMPLOYEE MEDICAL AND EXPOSURE RECORDS INFORMATION

TO A DESIGNATED REPRESENTATIVE

I, ____________________ (full name of the worker) hereby authorize

(Individual or organization holding the medical and exposure records) to release to

_______________ (individual or organization authorized to receive the medical information)
the following medical information from my personal medical/exposure records:

(Describe generally the information desired to be released)

I give my permission for this medical information to be used for the following purposes:

Full Name of Employee Date

_____

Full Name of Designated Recipient of Record Copies of the above records were released to

On Recipient Date

Representative-Title Medical Advisor

Page 17 of 22
MEDICAL RECORDS (C)
RELEASE OF EMPLOYEE MEDICAL AND EXPOSURE RECORDS INFORMATION

TO A DESIGNATED REPRESENTATIVE

I, ____________________ (full name of the worker) hereby authorize

(Individual or organization holding the medical and exposure records) to release to

(individual or organization authorized to receive the medical information) the
following medical information from my personal medical/exposure records:

(Describe generally the information desired to be released)

I give my permission for this medical information to be used for the following purposes:

Full Name of Employee Date

Full Name of Designated Recipient of Record

Copies of the above records were released to

on Recipient_Date

Representative-Title

Medical Records (d)

Medical records SAMPLE LETTER

Page 18 of 22
Mr. XXX, Business Manager

Any place

P.O. Any Box

Somewhere,

Dear Mr. XXX:

According to Local Law, an employer is required to inform employees of the location of medical
records associated with exposure to toxic substances.

We therefore are informing you that after the close out of our XXXXX GdC, these afore
mentioned medical records shall be retained by the QHSSE office XXX address.

Very truly yours,

QHSSE Manager

MEDICAL RECORDS (E)

(To be completed by the supervisor and taken to physician by employee.)

Please render medical service to __________________________________________ who is

employed by Contractor and is presumed to have sustained an injury or illness in the course
of employment. If hospitalization and/or medical treatment is required in excess of the limit

Page 19 of 22
provided by the Workers’ Compensation Law of the state in which the injury occurred, the
company will not be liable for the excess unless written authority for such treatment is first
obtained from the Company, or its designated representative.

* GDC requires all employees with doctor-treatable, work-related injuries or illnesses to

submit to a drug/alcohol screen. Call number listed below for details.

Date:

Phone Number:

BY:

TITLE:

Page 20 of 22
PHYSICIAN ’S RELEASE

(To be completed by physician and given to employee.)

To: __________________________, whom I have treated for an injury/illness is hereby

released:

To resume duty while ensuring the injury is not aggravated.

No additional treatment is required.

A follow-up appointment has been scheduled on (date)__________________

Restricted to work only as described below

No work allowed.

Attending Physician _____________________ Date_____________________

* Employee must present this form to his / her supervisor immediately after each physician
visit.

(Supervisor will fill in below and return to: Benefits Coordinator.)

The above-named employee returned to work on ________________________and has been

assigned to duties in accordance with the physician’s release.

Job No. ___________________________ Signed

Title ______________________________________

Date ______________________________________

Page 21 of 22
 APPENDIX D
EMPLOYEE PERSONAL HEALTH FILE
1. An Employee Personal Health File shall be formulated for an employee after the
following incidents have occurred:

a. Injury requiring doctor's care (work related)

b. Known allergies

c. Discovery of an illness requiring observation - Example: Hypertension

(monitoring of BP), recent surgery, alcoholism, drug abuse.

2. An employee Personal Health File shall contain information of the following nature:

a. Allergies - Example: Allergic to Penicillin

b. Existing illnesses, injuries - Example: Hypertension, diabetes, heart disease,

asthma, nervous disorders, hay fever, stomach problems, repaired hernias, old
back injuries

c. Medications being currently used or prosthesis needed

d. Major Operations - Example: Open heart surgery

e. Disabling injuries or illnesses of a temporary nature

3. A progress record shall be kept within the Employee's Personal Health File as a record
for injuries or illnesses which have developed while working on the job site.

4. The following records should be included within the Employee's Personal Health File:

a. Progress record

b. Employer's First Report of Injury/Illness

c. Physician's Referral Form

d. Physician's Report

e. Copies of any medication or doctor's bills from work related injuries

f. Medical test results from work related injuries

g. Lost Time Accident Record

h. Medication and immunization record

i. Medical Examination

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