BHP Authorization

BHP Authorization
Testing Location*
Company*
Requested By:*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date
PO#
Employee Name*

First NameLast Name
SS#*
Employee DOB

MonthDayYear
Date
Position*
Reason For Visit*

Pre-EmploymentPre-Access/EntryPeriodic/AnnualRandomPost-AccidentReturn To WorkReasonable CauseFollow-UpReturn-To-DutyOther
Services*

Drug ScreensAlcohol TestingPhysical ExamFCEFit TestAudiometryLab TestComputer Based Training (CBT)Other Medical Services
Lab Test*

CMP/CBC/LiverCBCUrinalysisBlood Lead / ZPPUrine PhenolBlood BenzeneHemoccultHIVRPR/VDRLTB SkinTB Gold - bloodworkOther
Fit Test*

OSHA Respirator QuestionnairePulmonary Function Test (PFT)1/2 FaceFull Face
1/2 Face Mask:*
Full Face Mask:*
Drug Testing*

Quick TestNON DOT UrineDOT UrineDISAHair TestOral FluidObserved
Quick Test*

51012
DISA Drug Screen*

UrineHairOralDOT
Alcohol Testing*

NON DOTDOTDISABreathSaliva
DOT Agency*

FMCSAPHMSAFTAFAAFRAUSCG
CDL#
DISA Consortium*

NASAPDCCHADCCHTDCCOFOther
DISA Form Fox Test Code
Audiometry*

BaselineComparisonRe-test
Physical Exam*

DOT/CDLBasic ExamCrane OperatorCoast Guard ExamReturn to workFit For DutyAsbestosSilicaOther
Silica Required Testing*

physical exam, b-reader, pft, tb test (blood)physical exam, b-reader, pft, tb test (skin)
Asbestos Required Testing*

physical exam, b-reader, pft,
Other Services*

EKGChest X-RayLumbar X-RayVision (Titmus)Vision (Jaegar)Vision (Ishihara)ImmunizationOther
Chest X-Ray Views*

121 view b-reader
Lumbar X-Ray Views*

235
Immunization*
Should be Empty: