Periodic Medical Surveillance Exam Note (Hazard Exposure)

Date/Time: [Date and time of examination] Location: [Clinic location] Clinician: [Examiner name and credentials]

Patient Name: [Employee full name] DOB: [Date of birth] MRN/Employee ID: [Identifier]

Employer: [Employer name] Worksite/Department: [Site/Department/Unit]

Hazard Program(s): [Applicable hazard program(s)] (List all programs tied to this visit, e.g., Silica Surveillance, Lead Surveillance, Respirator Medical Clearance, Noise/Hearing Conservation, HAZWOPER, Asbestos, Bloodborne Pathogens.)

Regulatory Basis: [OSHA standard reference / internal policy ID / Employer policy]

Exam Type: [Baseline / Periodic / Termination / Post-incident]

Last Surveillance Date: [Date or "None"] Next Due: [Calculated due date or "To be determined"]

Reason for Visit: [Reason for surveillance visit]

Purpose and Scope

[Brief statement of purpose] (In 2–3 sentences, state this is medical surveillance for the specified hazard program(s), covering exposure profile, targeted symptom review, focused examination, required testing, and surveillance planning. Note if respirator/PPE clearance or fitness-for-duty determination is included. State this does not replace routine primary care.)

Occupational and Exposure Profile

Current Job/Tasks: [Job title, essential tasks, shift pattern, tenure in role, physical demands relevant to PPE burden including exertion level, heat exposure, confined spaces, and expected PPE wear time]

Hazard Inventory: [For each applicable program: agent/exposure category, route(s) of exposure, frequency and pattern] (Specify inhalation/dermal/ingestion/mucosal/needlestick; days/year and hours/day; episodic vs continuous.)

Exposure Quantification: [Summary of air monitoring and/or biological monitoring including TWA/PEL, sampling dates, and source] (If unavailable, state "Exposure metrics not provided—requested [date]." Do not infer exposure levels from job title alone.)

Controls and PPE: [Engineering controls, administrative controls, respirator type/model and cartridge/filter if applicable, fit-test status and date, other PPE, typical duration and conditions of wear]

Prior Occupational Exposures: [Condensed timeline of relevant prior exposures across employers pertinent to current surveillance program]

Exposure Incidents: [Date, nature of incident, immediate symptoms, decontamination, initial evaluation/follow-up] (Required for post-incident exams. Omit this field if no relevant incidents.)

Medical History (Hazard-Relevant)

Relevant Medical/Surgical History: [Conditions affecting hazard risk or PPE tolerance, e.g., cardiopulmonary, renal, neurologic, dermal conditions pertinent to the hazard] (Omit unrelated conditions.)

Relevant Medications: [Medications impacting monitoring interpretation or safety]

Relevant Allergies: [Allergies to exposures or PPE materials including latex, adhesives, cleaning agents, or chemical sensitizers]

Tobacco/Vaping Status: [Status and pack-years] (Include when respiratory hazards or respirator/SCBA clearance are relevant.)

Prior Surveillance Baselines: [Spirometry, audiogram, chest imaging classification, biomarker values with dates and sources]

Interval History and Symptom Review

Interval Changes: [Changes since last surveillance in duties, controls, PPE, exposure frequency, and any new relevant diagnoses]

Targeted Symptom Assessment: (Include only symptom categories relevant to the selected hazard program(s). Omit categories not applicable.)

• Respiratory: [Cough, dyspnea, wheeze, chest tightness, sputum, hemoptysis, exercise tolerance, work-related pattern]
• Dermal/Mucosal: [Rash, irritation, sensitization pattern, nasal/oral irritation]
• Neurocognitive: [Headache, concentration difficulties, paresthesias, tremor, weakness, balance]
• GI/Constitutional: [Abdominal pain, appetite changes, fatigue, weight change]
• Hearing: [Tinnitus, speech discrimination difficulty, hearing protector tolerance]
• Renal: [Edema, urine changes, flank pain] (Include when nephrotoxic hazards apply.)

(For positive symptoms, document onset, duration, severity, timing relative to work/exposure peaks, and improvement away from work.)

Physical Examination

Vital Signs: BP [Blood pressure], HR [Heart rate], RR [Respiratory rate], SpO₂ [Oxygen saturation], Weight/BMI [Weight and BMI when relevant to respirator burden]

General: [Appearance, work of breathing, acute distress]

Targeted Examination: (Include only systems relevant to the hazard program(s). For systems not examined, state "Not examined.")

• Respiratory: [Chest inspection, auscultation, signs of chronic lung disease, clubbing, cyanosis]
• Dermal/Mucosal: [Skin at exposure sites, nasal/oral mucosa]
• Neurologic: [Screening mental status, cranial nerves, motor, sensory, coordination, gait]
• Cardiovascular: [Rate/rhythm, murmurs, edema] (Include when respirator/SCBA/heavy exertion clearance is applicable.)

Surveillance Testing and Results

Program Requirements: [List required tests for this interval with status: Completed today / Completed within window (date) / Ordered-Pending / Not performed (reason)]

Laboratory/Biomonitoring: [Test name, date, result with units, reference range, prior value for comparison, interpretation: normal / abnormal / borderline]

Spirometry: [FEV1, FVC, FEV1/FVC ratio, percent predicted, LLN, quality assessment, posture] (If abnormal or poor quality, document repeat plan. Include only when applicable to hazard program.)

Chest Imaging: [Imaging type, date, reader qualifications, classification result] (For pneumoconiosis programs, include ILO classification by B-reader when required. Include only when applicable.)

Audiometry: [Baseline date, current test date, STS comparison outcome, pre-test quiet compliance, follow-up actions] (Include for noise/hearing conservation programs.)

Other Testing: [Additional program-specific tests with dates, results, and prior comparison as applicable]

Pending Results: [List pending tests, expected result date, plan for review and employee notification] (Note if pending results affect timing of employer written opinion.)

Assessment

Surveillance Summary: [Synthesis of hazard(s), exposure context, symptom findings or absence, objective/test findings, and comparison to baseline or prior surveillance]

Trend Interpretation: [Trend direction and clinical significance for serial measures; confirmation strategy if concerning decline is identified]

Work-Relatedness: [Differential addressing occupational and non-occupational contributors] (Include when symptomatic or abnormal. Use language such as "consistent with," "concerning for," or "cannot exclude.")

Fitness/Clearance Determination: [Cleared / Cleared with restrictions / Not cleared / Pending test completion] (If restrictions apply, state functional and PPE-specific guidance, e.g., "No negative-pressure respirator; PAPR acceptable" or specific heat/exertion limitations.)

Plan

Immediate Actions: [Orders placed, repeat/confirmatory testing, referrals, additional diagnostics with responsible party and timeframe]

Work Restrictions/Protective Measures: [Clinical recommendations] (Note that employer-facing opinion will include only allowable elements under the program.)

Counseling Provided: [Hazard-specific risk counseling, early symptom reporting instructions, smoking cessation counseling if relevant, PPE/respirator use guidance]

Surveillance Schedule: [Next due date and required components; triggers for earlier re-evaluation including new/worsening symptoms, exposure incident, change in PPE/respirator type, or change in work demands]

Result Communication: [Method and timeline for communicating results to employee, including plan for pending results]

Employee Counseling Documentation

Results Reviewed with Employee: [Yes / No], [Date], [Method: in-person / telehealth / phone / secure message]

Education Provided: [Topics covered and materials provided]

Restrictions and Rationale Discussed: [Yes / No; summary of discussion]

Employee Understanding: [Employee verbalized understanding / Teach-back completed / Questions pending follow-up]

Employer-Facing Written Opinion (Restricted Content)

(This section generates a separate employer communication. Content is limited to what is permitted under the applicable program. Do not include unrelated diagnoses or non-occupational findings. If expanded disclosure is contemplated, document explicit written employee authorization.)

Date of Examination: [Date]

Program Requirements Met: [Yes / No / Pending completion of (specify)]

Recommended Limitations: [Functional and PPE-specific limitations, or "No limitations recommended"]

Employee Notification: Employee has been informed of medical examination results: [Yes]

(If results are pending, state that the written opinion will be finalized upon receipt per program requirements.)

Source Documents and Attachments

[Exposure data/industrial hygiene reports with source and date; employer-provided job description; PPE specifications and fit-test records; completed questionnaires (respirator medical questionnaire, hazard-specific symptom questionnaires); test reports (spirometry with flow-volume curves, audiograms, laboratory reports, imaging classifications)]

(For required-for-compliance fields with missing information, insert "Not provided—requested [date]." Omit optional fields not applicable to the selected hazard program(s).)