/ Occupational Health Services (OHS)
420 Lexington Avenue, 22nd Floor
New York, New York10017

Voice (212) 499 – 4720

Fax (212) 499 – 4740

REQUEST FOR OCCUPATIONAL HEALTH SERVICES

Time In:
SERVICES REQUESTED (see reverse side for definitions). Please type or print using a ballpoint pen.
SUPERVISOR’S SECTION
(Press Hard- You are making five copies) / Last Name / First Name / MI / Appt Date/Time
Employee # / SS # (for pre-placement use only) / Birth Date / Home Telephone
Home Address / City / State / Zip Code
Occupation / Tour of Duty / Rest Days
Mon
Thurs
Sun / Tues
Fri / Wed
Sat / Department/Location
Supr. Location if different:
From
____:____am To ____:____pm
From
____:____pm To ____:____am
Supervisor/Recruiter
Print Sign / Date / Supervisor ‘s Telephone & Fax Numbers
Tel: Fax:

INCIDENT VISIT

First Visit
Revisit
Incident Date
______/______/______/ Incident Report Filed /

EXAMS

Pre-placement
Periodic ______
Gang Watchman
Asbestos
DOT/CDL
Fire Brigade
Hepatitis B Vaccine/Titre
Lead
Respirator
Change of Craft to:
______
Special Evaluation/Other:(* see reverse for definition)
______/

TOXICOLOGICAL TESTING

Reasonable Suspicion
Reasonable Cause
(See Reverse for Definition)

EMPLOYEE CURRENTLY WORKING?

/ DOES EMPLOYEESTATE THIS IS SERVICE CONNECTED? / Job Change to Safety Sensitive:
Agreement
Non-Agreement

Yes

/

No

/

Yes

/

No

REASON FOR VISIT

Occupational
Non-Occupational
Furlough
Suspension, Dismissal, Discipline
Leave of Absence (FMLA, Military, Personal)
Other (Specify)______
OHS REPORT OF VISIT / Occupational
Non-Occupational
Off-Duty Occupational
Pending Review and Determination
Mandated Exam / Visit
Visit
Visit / Revisit
Revisit
Revisit

STATUS

Qualified / Full Duty / Restricted Duty / Effective Date / Follow-up Visit
/ / / Date______
Not Qualified / Temporarily Not Qualified
(pre-placement use only) / Time______
COMMENTS AND RESTRICTIONS
Required / Corrective Lenses / Hearing Aid / Other (specify) / See MD2 for Information
IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT:
Examiner’s Name (print)
Examiner’s Signature / Date / Time Out

CC: Safety & Claims Services

/ Telephone
212-499-4720
Yes / No / MD-40//Rev 8/2004
White: Supervisor / Pink: OHS / Yellow: Claims Services / Blue: Safety / Green: Employee

This request for Occupational Health Services form also functions as a Report of Examination. It is a five (5) part form with the recipients designated (on the bottom of the first page) as follows: White: Supervisor; Pink: OHS; Yellow: Claims Services; Blue: Safety; Green: Employee.

INSTRUCTIONS FOR SUPERVISORS:

  • The request for Occupational Health Services section must be prepared IN FULL by the Employee’s immediate supervisor or the departmental designee before an OHS examination may be performed. NOTE: The Supervisor must provide his/her telephone and fax numbers.
  • “Occupation” refers to the specific job the employee is doing at the time of the REQUEST.
  • For Work-related Incidents, please refer to the Post Incident Management Guidelines.
  • If the supervisor has any questions upon receipt of the completed MD-40, he/she should contact the OHS professional who signed the MD-40.

REASON FOR VISIT:

  • Check the type of exam you are requesting.
  • A Confidential Letter of Explanation should accompany request for Fitness for Duty evaluations as deemed necessary by the supervisor, along with available documentation explaining why it is felt the employee is unable to perform his/her job.
  • Drug tests

REASONABLE SUSPICION

  • You observed the behavior, appearance, speech and/or body odor of employee and suspect use of intoxicant based on one or more of the following criteria:

Staggers/Difficulty WalkingDisorientation (time/place/person)

Slurred SpeechRapid Mood Swings for No Reason

Drowsiness/SleepinessPoor Coordination/Body Control

Odor of IntoxicantBizarre Behavior

Direct Observation of the Use of an Intoxicant

REASONABLE CAUSECovered Employees

  • Where there is
  • An accident or incident reportable under 49 C.F.R. Part 225, and a supervisor has a reasonable belief based on specific, articulable facts, that the employee’s acts or omissions contributed to the occurrence or severity of the accident or incident.
  • A rule violation as set forth in 49 C.F.R. section 219.301.
  • With respect to Commercial Drivers and Safety Sensitive Employees, where there is:
  • An accident, incident or rule violation giving rise to Reasonable Cause testing for covered employees, or
  • An accident or incident involving a motorized vehicle where the accident was not due to mechanical failure or the negligent action of a motorist other than Safety Sensitive and the Safety Sensitive employee was driving a motorized vehicle involved in the accident which results in:
  • The loss of human life
  • Bodily injury to the employee or others requiring medical attention away from the scene
  • The vehicle being transported away from the scene
INSTRUCTIONS FOR THE EMPLOYEE
  • IMPORTANT!Your attendance at any schedule appointment @ The MTA/Metro-North OHS is MANDATORY. You must bring any and all documents from your doctor for review by the OHS. The purpose of your visit to the OHS is to determine your fitness to perform the duties of your position. Failure to attend any and all appointments at the OHS may result in the institution of disciplinary charges against you up to and including dismissal.
  • Please be aware that at every visit for an evaluation, you MUST be prepared for the possibility of immediate return to work on either full or restricted duty.
  • If you are fully qualified by the OHS Department, you must exercise seniority consistent with the terms of your collective bargaining agreement.
  • You must report to your supervisor immediately upon exiting the OHS Department.
  • NOTE: Children under age twelve cannot be left unattended in the waiting room. Please consider suitable arrangements.

Rev 8/2004