Medical Services Request Form

Request Date:

Elite will call to set up a time

Request ID:

Reason for Test

Follow Up

Pre-Employment

Post-Accident

Reasonable Suspicion

Random

Return to Duty

Other (Specify)

Worksteps

Worksavers

Post Offer Pre-emplyment Screen (POPS)

Fit-for-Duty Assessment

Company Specific Physical Ability Testing

Physical DOT (Federal)

Physical Non-DOT

Respiratory Questionaire (RQ) - OSHA

Pulmonary Function Test (Spirometry) - OSHA Certified

Quantitative Respirator Mask Fit

Audiometry (CAOHC Certified)

Urine Drug Screen

DOT (Federal)

Non-DOT

Breath Alcohol

DOT (Federal)

Non DOT

Rapid Drug Screen

5 Panel

10 Panel

12 Panel

Hair Drug Screen

Medical Services Request Reader

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Request Date:

Request ID:

Reason for Test

Workability Testing

Physicals Examinations

Respiratory Protection

Hearing Conservation

Drug & Alcohol Testing

Urine Drug Screen

Breath Alcohol

Rapid Drug Screen

Hair Drug Screen

Additional Requirements

Elite Health & Fitness

Site Administration