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Safety & Risk Management

Occupational Medical Monitoring Program Contact Information

Juli A. Smith, CIH
Director, Safety and Risk Management
Phone: 661.654.2066
Fax: 661.654.6117

E-mail: jsmith101@csub.edu

Mail Stop: 37ADM

To schedule an appointment At CVO, or if you have questions regarding the filling out of the forms listed below please contact:

Sheila Barela

EH&S Specialist

Phone: 661.654.6320

E-mail: sbarela@csub.edu

Occupational Medical Monitoring Program 10.28.2012 NEW

Access to Medical and Exposure Records (Cal-OSHA Poster English)

Access to Medical and Exposure Records (Cal-OSHA Poster Spanish)

Medical Monitoring Forms

1

Required Employee Occupational Medical Monitoring Memo (S&RM to Supervisor)

Required Occupational Medical Monitoring Notification Memo (Supervisor to Employee)

CVO Patient Referral Form (S&RM to Supervisor and Employee)

Confidentiality Statement and Authorization to Release Medical Information Form

(Employee to CVO)

CVO Physical Exam Forms for Asbestos Workers (Complete Package)

CVO Physical Exam Forms for Non-Asbestos Workers (Complete Package)

CVO / CSUB Occupational Medical Monitoring Form (Employee to CVO)

CSUB Employee Exposure Table (Employee, Supervisor review, to CVO)

CVO Hearing Test Questionnaire (Employee to CVO)

CVO Medical Respirator Recomendation Form (Employee to CVO)

Hep B Authorization and Declination Form (Employee to CVO)

Hep A Authorization and Declination Form (Employee to CVO)

Occupational Medical Monitoring Declination Form (Employee to S&RM)

CVO Physicians Status Report Form (CVO to S&RM)

CVO Individual Audiogram Report Form (CVO to S&RM)


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Last modified on: Wed., Nov. 14, 2012 - 03:32:10 PM
Your local time: Wed., Jun. 19, 2013 - 03:37:29 PM