Ethylene Oxide

Chapter 296-855, WAC

Effective Date: 01/01/06

 

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WAC 296-855

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Sample Medical Evaluation Declination Form Optional

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Use with Ethylene Oxide Rule, Chapter 296-855 WAC

 

Employer______________________________________________

I understand that because of my occupational exposure to ethylene oxide, I may be at risk for serious health effects including __________.

You have given me the opportunity to receive medical examination and testing for the potential health effects from ethylene oxide exposures, at no cost to me. However, I decline to receive this medical examination and testing at this time.

I understand that by declining medical examination and testing, I continue to be at risk for ________ and other health effects related to ethylene oxide exposure.

I understand that I must have a medical evaluation to wear a respirator and without such an evaluation I can't wear a respirator as part of my job. I also understand that declining to receive medical examination and testing for health effects from ethylene oxide exposures does not exclude me from receiving a separate medical evaluation for respirator use.

If, in the future, I continue to have occupational exposure to ethylene oxide and decide to receive medical examination and testing, I will be given the opportunity to receive them at no cost to me.

_________________________________________________
Employee’s Name (Print)

_________________________________________________
Employee’s Signature

__________________
Date

 

 

 

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