Authorization for Testing
Company Information
Company
*
Excel Mod
Next Generation Scaffold Services
GMTS
Precision
Authorized By:
*
First Name
Last Name
E-mail
PLEASE SEND ALL RESULTS TO
NETWORK@GULFCOASTOCCMED.COM
Employee Information
Employee Name
*
First Name
Last Name
Employee Social Security Number
No spaces
Employee Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Date of Testing
*
-
Month
-
Day
Year
Date Picker Icon
Clinic
Location
*
Airline
Baton Rouge Safety Council
Walker
Reserve
Addis
Gonzales
Business Health Partners- 3649 S Beglis Pkwy, Sulphur, LA
Business Health Partners- 7406 Up River Rd, Corpus Christi, TX 78409
Business Health Partners- 422 E Dove Ave, McAllen, TX 78504
Occupational Testing
Please select job site and reason for testing
Job Site
Citgo
Sasol
Placid
Dupont
Dow
Marathon
Shell-Convent
Shell-Geismar
Shell-Norco
Yard
HF Sinclair Tulsa
Reason for testing
Pre-Employment
Annual
Craft
Scaffold
Insulator
Asbestos
Painter
Mechanical
Refractory
DISA DRUG TESTING
DCCHA
DCCOF
DCCHT
DCCHT with Randoms
DISA BREATH ALCOHOL
Placid
Non-DOT Physical
Baseline Audio
HF Sinclair Tulsa
Non DOT physical
Baseline Audio
3m 6000 1/2 face
Scott AV 2000 FF
PFT
Disa Drug Screen- HF Sinclair Tulsa
Dccha drug and alcohol
EXXON
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 1/2
Scott AV3000
DISA NASAP DRUG
DISA NASAP BREATH ALCOHOL
Yard
Non-DOT Physical
Baseline Audio
Yard
Non-DOT Physical
Annual Audio
Shell- Convent- Scaffold
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Shell- Convent- Insulator
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Complete Asbestos Physical
Shell- Convent- Scaffold
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Shell- Convent- Insulator
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Complete Asbestos Physical
Dow
Non-DOT Physical
Baseline Audio
Shell Norco- Insulator
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Shell Geismar- Insulator
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Citgo- Insulator
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Sasol- Insulator
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Shell Geismar- Insulator
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Shell Norco- Painter
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
LEAD
PFT
B read Chest X-Ray (1 view)
T-Spot TB Test (Blood)
Crystalline Silica Questionaire
Shell Geismar- Painter
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
LEAD
B Reader Chest X-Ray (1View)
T-Spot TB Test (Blood)
Crystaline Silica Questionaire
Pulmonary Function Testing
Citgo- Painter
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
3m 6000 Series FF
Scott AV3000 FF
Pulmonary Function Testing
LEAD
B Reader Chest X-Ray (1View)
T-Spot TB Test (Blood)
Crystaline Silica Questionaire
Sasol- Painter
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
LEAD
B Reader Chest X-Ray (1View)
T-Spot TB Test (Blood)
Crystaline Silica Questionaire
Pulmonary Function Testing
Shell Norco- Insulator
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
Shell Norco- Painter
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
LEAD
Shell Geismar- Painter
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 FF
LEAD
Shell Norco- Scaffold
Non-DOT Physical
Baseline Audio
3m 6000 Series 1/2F
Scott AV3000 FF
Clearance
Shell Geismar- Scaffold
Non-DOT Physical
Baseline Audio
Citgo- Scaffold
Non-DOT Physical
Baseline Audio
3m 6000 Series 1/2f
3m 6000 Series FF
Scott AV3000 FF
PFT
Sasol
Non-DOT Physical
Baseline Audio
Shell Geismar- Scaffold
Non-DOT Physical
Annual Audio
Placid
Non-DOT Physical
Annual Audio
Dow
Non-DOT Physical
Annual Audio
Dupont- Scaffold
Non-DOT Physical
Annual Audio
Diamine Physical
Dupont- Insulator
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Diamine Physical
Marathon-Scaffold
Non-DOT Physical
Baseline Audio
Clearance
Scott AV3000 FF
3m 6000 Series 1/2F
Marathon Health History
GMTS- Mechanical
Non-DOT Physical
Baseline Audio
Clearance
Scott AV3000 FF
3m 6000 Series 1/2F
Marathon Health History
Precision- Refractory
Non-DOT Physical
Baseline Audio
Clearance
Scott AV3000 FF
3m 6000 Series 1/2F
Marathon Health History
Asbestos Physical
Silica Physical
Marathon- Painter
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Lead
Scott AV3000 FF
Marathon Health History
PFT
COMPLETE SILICA PHYSICAL
T Spot Blood Test
Dupont- Painter
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Lead
Marathon- Painter
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Lead
Marathon Health History
COMPLETE SILICA PHYSICAL
T Spot Blood Test
Marathon- Insulator
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
Scott AV3000 Full Face
Marathon Health History
Shell- Geismar- Asbestos
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
1 view Chest X-Ray
Physican Written Option
Citgo- Asbestos
Non-DOT Physical
Baseline Audio
PFT
3m 6000 Series 1/2F
1 view Chest X-Ray
Physican Written Option
3m 6000 Series FF
Scott AV3000 FF
Sasol- Asbestos
Non-DOT Physical
Baseline Audio
Clearance
3m 6000 Series 1/2F
1 view Chest X-Ray
Physican Written Option
Marathon- Asbestos
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
1 view Chest X-Ray
Physican Written Option
Marathon Health History
Marathon-Scaffold
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Marathon Health History
Marathon-Insulator
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Marathon Health History
Complete Asbestos Work UP
Dupont- Insulator
Non-DOT Physical
Annual Audio
Clearance
3m 6000 Series 1/2F
Diamine Physical
Drug Testing
Please select job site and reason for testing
Job Site for drug testing
Citgo
Sasol
Placid
Dupont
Dow
Marathon
Shell-Convent
Shell-Geismar
Shell-Norco
Yard
Reason for drug testing
Pre Employment
Annual
Random
Post-Accident
Reasonable Susp.
Other
Witnessed Collection
Yes
No
Drug and Alcohol
DCCHA w/ DISA BAT
Shell Convent
DCCHA
DCCHT With Randoms
DISA BAT
DCCOF
Marathon
DCCHA
Disa BAT
DCCHT
Drug Screening
DCCHA
DCCHT W/ RANDOMS
DCCOF
DISA BAT
DOW Drug Screening
DCCOF
DCCHT W/ RANDOMS
DISA BAT
DCCHA
Shell Norco -Scaffold
Non-DOT Physical
Annual Audio
Reason for Drug Screen
Pre Employment
Random
Annual
Post Accident
Reasonable Susp.
Other
Other Testing
Additional Services
10 panel Instacheck
Clearance (must be checked if checking mask)
3m 6000 Series 1/2 Face
3M 6000 series Full Face
Scott AV 3000
Lead Level
Pulmonary Function Test
Complete Silicia Physical
Return to Work Physical
Marathon Health History
Jobsite
Please send all results to:
*
network@gulfcoastoccmed.com
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