OSHA Medical Surveillance Written Medical Opinion (Employer/Employee)

Document Date: [date issued]

Document ID: [unique identifier for audit trail]

Document Status: [Final / Preliminary]

Clinic/Organization: [name, address, phone]

Examining Clinician: [name, credentials, license number if applicable]

To: [Employer company name and site/department]

Attention: [HR / Safety Officer / appropriate contact]

Re: OSHA Medical Surveillance Written Medical Opinion

Employee Copy: [Employee name]

Employee Identification

Employee Name: [full name]
Employee ID or DOB: [employee ID preferred; date of birth if ID unavailable]
Job Title: [job title / Not provided by employer]
Worksite/Location: [worksite/location / Not provided by employer]

OSHA Program and Examination Context

• Applicable OSHA Standard(s): [e.g., 29 CFR 1910.134; 1910.1053; 1910.1025; 1910.1001; 1910.1048; 1910.1028] (List all that apply.)
• Hazard(s)/Agent(s): [exposures in plain language]
• Exam Type: [baseline / periodic / termination / return-to-work / post-exposure / reassessment]
• Examination Date: [date]
• Key Testing: [test types and dates used for this opinion] (Do not include results unless required by the applicable program.)

Medical Determination

(State fitness only for the specific covered function(s) evaluated. Do not include diagnoses or unrelated medical details.)

Covered Function/Program	Determination	Scope/Notes	Effective Date	Expiration/Review Date
[e.g., Respirator use; Exposure work for specified hazard]	[Fit for duty without restrictions / Fit for duty with restrictions / Not fit for duty / Temporary deferral pending specified items]	[functional notes only; no medical detail]	[date]	[date / per program interval]

(Add rows if multiple covered functions/programs were evaluated.)

Work Limitations and Restrictions

(If no restrictions apply, state "No restrictions recommended at this time" and omit table.)

Restriction Domain	Specific Restriction	Duration	Implementation Notes
[exposure / respirator use / PPE / heat stress / exertion / schedule / other]	[clear, measurable, functional limitation]	[temporary until date / permanent / pending re-evaluation date]	[employer guidance only; no medical details]

Required Follow-Up

Follow-up needed: [Yes / No]

(If No, omit table below.)

Action	Timeframe	Clearance Impact	Responsible Party
[Re-evaluation / Repeat test / Specialist evaluation / Other]	[within 30 days / before next annual clearance / by specific date]	[Cleared; no impact / Cleared pending completion / Not cleared until completed]	[Employer / Employee / Clinic / Shared]

Program-Specific Elements

(Include only the sections below that apply to this evaluation.)

Respirator Medical Evaluation (29 CFR 1910.134)

Medically able to use a respirator	[Yes / No / Conditional]
Cleared respirator type(s)	[APR half-face / APR full-face / PAPR / SCBA / other]
Limitations on respirator use	[functional limitations; e.g., no negative-pressure respirator; PAPR only / None]
Follow-up medical evaluation needed	[Yes / No] — [timeframe or trigger if applicable]

Silica Surveillance (29 CFR 1910.1053)

• Examination Date: [date]
• Program Compliance: Examination met program requirements.
• Recommended limitations on respirator use: [limitations / None]

(Do not include exposure limitations or referral recommendations unless written authorization has been obtained from employee.)

Lead Surveillance (29 CFR 1910.1025)

• Blood Lead Result(s): [value(s) with unit and date(s)]
• Increased risk of material impairment from lead exposure: [Yes / No]
• Recommended protective measures or exposure limitations: [functional guidance / None]

Asbestos Surveillance (29 CFR 1910.1001)

• Conditions increasing risk from asbestos exposure: [present / not identified] (State without diagnostic detail.)
• Recommended limitations on exposure and/or PPE/respirators: [recommendations / None]
• Employee informed of increased lung cancer risk from combined smoking and asbestos exposure: Yes

Formaldehyde Surveillance (29 CFR 1910.1048)

• Conditions increasing risk from formaldehyde exposure: [present / not identified]
• Recommended limitations on exposure and/or PPE/respirators: [recommendations / None]

Benzene Surveillance (29 CFR 1910.1028)

• Program-required result(s): [occupationally pertinent results and dates]
• Conditions placing employee at greater-than-normal risk from benzene: [present / not identified]
• Recommended limitations on exposure and/or PPE/respirators: [recommendations / None]

Confidentiality Statement

This written medical opinion is provided for OSHA compliance and is limited to information permitted or required under the applicable OSHA standard(s). It does not include specific findings, diagnoses, or unrelated clinical details except where disclosure is required by the governing standard.

Employee Notification Attestation

• The employee has been provided a copy of this written medical opinion: [Yes / No]
• The employee has been informed of the results and of any conditions requiring further evaluation or treatment: [Yes / No / N/A] (Include if required by the applicable program.)

Employee Authorization Status

(Include for silica and any program requiring written authorization for additional employer disclosures.)

• Written authorization obtained from employee: [Yes / No]
• If Yes, authorized categories for employer disclosure: [exposure limitations / referral recommendations / other]
• Authorization signed: [date]
• If No: Exposure limitation and referral recommendations are not included in the employer-facing WMO per regulatory requirements.

Clinician Signature

Signature: [electronic signature acceptable per policy]

Name: [printed name]

Credentials: [credentials and license number]

Date: [signature date]