IMT Authorization Form

  • IMT Authorization Form

    Complete this form with your details and testing requirements for occupational health authorization.

  • Header Info

  • Date*
     - -
  • Format: (000) 000-0000.

  • Reason for Test

  • Reason for test*
  • Select all reasons that apply.
  • Is this a follow-up test?
  • Is this related to an incident?

  • Lab Tests

  • Audiometry

  • Audiometry Type*

  • Vision Testing

  • Vision Testing Options*

  • Alcohol Testing

  • Alcohol Testing Methods*

  • Drug Test — Urine

  • Collection Type*
  • Urine Standard Test Panels
  • Urine Rapid Screen Test Panels
  • Urine Standard Collection Confirmation
  • Urine Rapid Screen Confirmation

  • Oral Fluid Drug Test

  • Oral Fluid Drug Test Panels*

  • Hair Drug Test

  • Hair Drug Test Panel*
  • Notes

  • Physical Exams

  • Physical Exam Type*

  • Pulmonary / Fit Test

  • Authorized Signature Section

  • Date*
     - -
  • Should be Empty: