Fitness to Work in Pressurized Settings
Medical Examiner Recommendations
National Board of Diving & Hyperbaric Medical Technology
9 Medical Park, Suite 440, Columbia, SC 29203 USA
E-Mail: nbdhmt@aol.com
www.nbdhmt.org
Certified Diver Medic Technician
Phone: (803) 434-7802 Fax: (866) 451-7231
Date:Physician Name:
PHYSICIAN Signature:
_______________________
* In compliance with the Americans with Disabilities Act, the medical
examiner may not list on this form either medical diagnoses or conditions.
Only restrictions and/or job-related tasks that cannot be adequately
performed by the applicant/employee are to be listed.
Applicant/Employee:
Employer:
Position Title:
Date of Birth:
Date of Exam:
Considering any job-related information provided to me by the employer: either before or upon my request
during the course of my evaluation, it is my opinion, that based on the results of the:
Physical Examination
Physical Agility Testing
Medical Testing, as required by ____________________________________
Medically cleared as fit to work in pressurized settings
The aforementioned individual is:
Contact: Tel:
Physician I.D. Stamp
Not cleared to work in pressurized settings
Email:
Medically cleared as fit to work in pressurized settings, except that a condition exists which limits work as follows: see attached
