Pre-Placement/Post-Offer Employment Physical Note

Encounter Information

Date/Time: [Date and time of exam]
Clinic/Site: [Clinic or mobile unit site]
Examiner Name/Credentials: [Name, degree(s), license/certification]
Employer Name: [Employer/company]
Job Title: [Position title under evaluation]
Job Category/Exam Package: [Package or program name] (Include only if applicable)
Work Location: [Worksite/campus/region] (Include only if relevant)

Purpose

[Purpose of exam] (1–2 sentences stating this is a post-offer, pre-placement fitness-for-duty evaluation for the specified position. Specify requested determinations such as [general medical clearance / respirator medical clearance / hearing baseline / immunization review / other].)

Consent and Disclosure Acknowledgment

• [Consent to evaluation] (Document that candidate understands the exam purpose is to determine fitness to perform essential job functions safely.)
• [Disclosure limitation acknowledgment] (State that only functional clearance status and restrictions will be shared with the employer; diagnoses and detailed medical information will not be disclosed unless explicitly authorized or required by regulation.)
• Employer release authorization: [On file / Not on file] (If on file, specify scope of authorization.)

Job Demands and Occupational Exposures

• Information source: [Employer job description / Physical demands analysis / Candidate verbal report only] (If no employer-provided demands are available, state: "Job demands not provided; clearance limited to general examination findings.")
• Essential functions summary: [Brief description of critical tasks tied to the role] (Focus on safety-sensitive and high-demand tasks.)
• Physical demands: [Lifting/carrying/pushing/pulling weights with frequencies (occasional/frequent/constant); required postures (climb ladders, kneel, squat, overhead reach); endurance (standing/walking duration); fine motor/hand use requirements] (Quantify weights and frequencies when available.)
• Environmental exposures: [Noise level; respirator/PPE required; heat/cold; chemicals/dust/fumes; confined spaces; infectious exposure risk; shift work/overnight] (Note any required medical surveillance program.)
• Safety-sensitive designation: [Yes / No / Unknown]
• Regulatory requirements applicable: [Respirator medical evaluation / Hearing conservation baseline / DOT-CDL / TB screening / OSHA surveillance (specify) / None]

Medical History

(Document sources reviewed and focus on conditions relevant to job function and safety. If information is unknown or not provided, record as "Unknown/not reported" rather than leaving blank.)

• Sources reviewed: [Candidate questionnaire / Prior medical records / Immunization records / Prior audiogram / Prior spirometry / Other]
• Current symptoms or concerns: [Candidate's stated current status and symptoms] (Use brief direct quotes only when clarifying functional impact.)
• Problem list (fitness-relevant): [Conditions relevant to job function and safety: cardiovascular, neurologic (seizure/syncope), pulmonary, musculoskeletal, vision/hearing, diabetes/metabolic, sleep disorders, psychiatric conditions affecting safety] (Document in problem-list format with brief functional relevance.)
• Surgical history/hospitalizations: [Brief, fitness-relevant summary]
• Current medications: [Medication name – dose – frequency] (Flag medications with safety implications: [sedating / hypoglycemia risk / other].)
• Allergies: [Allergen and reaction type] (Note latex allergy specifically if gloves/PPE are required.)
• Targeted occupational history: [Prior similar work; prior work-related injuries or restrictions; exposure-related conditions or surveillance participation]
• Tobacco/nicotine use: [Type; quantity; duration; quit date if applicable]
• Substance use history: [Include only if required by exam program; otherwise state "Not assessed per program scope."]
• Immunization/TB status: [Vaccine history and documentation status; TB screening history and dates/results] (Include for healthcare or high-exposure roles.)
• Job-focused review of systems: [Pertinent positives/negatives related to essential functions: exertional chest pain, syncope, dyspnea, vertigo, seizure history, musculoskeletal pain impacting tasks, visual/hearing concerns]

Physical Examination

• Vital signs: [BP; HR; RR; SpO2 (if respiratory risk applies); Height; Weight; BMI]
• General: [Appearance; distress; gait]
• HEENT: [Gross vision; pupils; oropharynx]
• Cardiovascular: [Rate/rhythm; heart sounds; peripheral pulses if relevant]
• Pulmonary: [Effort; breath sounds; exertional tolerance observations]
• Skin: [Rashes/dermatitis; areas at risk given exposures]
• Musculoskeletal: [Spine ROM; major joints ROM/strength; functional maneuvers aligned to job demands]
• Neurologic: [Orientation; balance; coordination; gross motor/sensory] (Include focused balance/coordination testing for safety-sensitive roles.)
• System(s) not examined: [List and reason] (Document "Not examined" with rationale rather than implying normal.)
• Job-specific testing (if performed):
  • [Vision testing: distance/near acuity; corrective lenses; color vision; standard met]
  • [Audiometry: baseline vs annual; thresholds; interpretation]
  • [Respirator/PPE tolerance assessment: questionnaire review; focused exam findings]
  • [Functional testing: protocol used; observed performance; termination criteria; adverse symptoms]

Testing and Screening Results

(Include only tests performed. Do not list planned or pending items in this section.)

• [Vision testing results and interpretation]
• [Audiometry results and interpretation; note baseline vs annual]
• [Urinalysis or laboratory results relevant to clearance]
• [Spirometry: FEV1, FVC, FEV1/FVC, quality grade and interpretation]
• [EKG or other diagnostics with interpretation]
• [TB testing and immunization verification status]
• [Other completed tests and results]

Pending items: [Tests or documents pending; expected turnaround time; impact on clearance: [provisional clearance issued / clearance deferred pending results]]

Drug/alcohol testing: [Address only aspects needed for medical decision-making per clinic policy; chain-of-custody documentation handled separately.]

Assessment

(Provide a fitness-focused clinical summary. Link each finding to functional relevance and job demands. Do not infer diagnoses; document uncertainty when present.)

• Fitness-impacting conditions: [Each condition or finding with brief supporting data and relevance to essential functions/safety]
• PPE/exposure tolerance considerations: [Respirator tolerance; heat/cold intolerance; dermatitis with required PPE]
• Incidental health maintenance findings: [Findings not directly affecting fitness] (Clearly separate from fitness determination.)
• Uncertainty/additional data needed: [Information or testing required to complete determination]

Fitness Determination

(Base determination on documented findings and the Job Demands section. State restrictions in functional terms, not diagnostic labels.)

• Clearance category: [Medically Qualified – No Restrictions / Medically Qualified – With Restrictions/Accommodations / Qualification Deferred – Additional Information/Testing Required / Not Medically Qualified for This Role at This Time]
• Job demands referenced: [Specific demands used to make determination]
• Restrictions (if applicable): [Functional restrictions in objective terms: weights, durations, postures, environments; start date; anticipated end date or re-evaluation date; temporary or permanent; applies to all duties or specific tasks]
• Deferral requirements (if applicable): [Required information/testing; interim work limitations until completion]
• If not medically qualified: [Objective functional/safety basis; note if reasonable accommodation may mitigate risk]

Employer Communication

(Maintain strict separation between clinical documentation and employer-facing output per ADA confidentiality requirements.)

• Information released: [Clearance category; functional restrictions; recommended follow-up timeframe] (Do not include diagnoses, detailed history, medications, or test values unless specifically required and authorized.)
• Recipient and method: [Name/department; portal/fax/encrypted email] [Date/time sent]
• Candidate authorization: [On file / Not on file] (If on file, specify scope.)

Candidate Counseling and Follow-Up

• [Explanation of abnormal findings provided to candidate] (Include education on significance and urgency if applicable.)
• [Referrals/recommendations: PCP, specialist, urgent care/ED] (Provide timeframe.)
• [Preventive guidance related to job hazards: hearing protection, heat safety, ergonomic/PPE use]
• [If clearance deferred: what candidate must provide and deadline]

(If fully qualified with no restrictions and no abnormal findings, state: "No additional counseling required.")

Attestation

[Examiner signature with credentials and date/time]

Regulatory Addenda

(Append applicable addenda below. Include only those relevant to this examination.)

Respirator Medical Evaluation Addendum

• Standard referenced: [OSHA 29 CFR 1910.134 / Other]
• Questionnaire reviewed: [Yes / No]
• Medical findings relevant to respirator use: [Summary]
• Respirator types cleared: [N95/FFR / Elastomeric half-face / Full-face / PAPR / SCBA] (Note any limitations.)
• Clearance status: [Cleared / Cleared with limitations / Not cleared / Deferred pending data]

Hearing Conservation Audiometry Addendum

• Type: [Baseline / Annual / Follow-up]
• Environment controls: [Noise-free interval documented; booth calibration date]
• Results summary: [Thresholds and interpretation]
• Counseling provided: [Hearing protection education; follow-up plan]

Healthcare Worker TB/Immunization Screening Addendum

• TB screening: [IGRA/PPD type; date; result; CXR status if indicated; symptoms screen]
• Immunizations reviewed: [MMR; Varicella; Hep B; Tdap; Influenza; COVID-19; others] (Include documentation status.)
• Requirements met: [Yes / No] (If no, specify needed vaccines/tests.)

DOT/CDL Examination Addendum

[Document FMCSA-required elements per program protocol using official certification forms, including certificate duration and restrictions.]

OSHA Medical Surveillance Addendum

• Program: [Lead / Asbestos / Silica / Hexavalent Chromium / Hazardous Waste / Other]
• Standard referenced: [29 CFR section]
• Surveillance elements completed: [History; exam; labs; spirometry; other]
• Medical opinion to employer: [Fitness for exposure; PPE suitability; limitations; follow-up needed] (Do not disclose diagnoses unless required by standard.)