ePassport

*AI150805098U*
AI150805098U

Clinics with eScreen123 must scan passport into eScreen123. Complete all services.

Clinic Information:

MAP

Yampa Works Occupational Health

3001 S Lincoln Ave
Ste A
Steamboat Springs,CO 80487
ph #:970-875-2750
Fax: 970-875-2780

DON'T FORGET!
- Take ePassport and Photo ID
- Call Clinic to schedule an appointment for services
- Take all Documents that print with this ePassport

Scheduled Time:

Between 3/3/2016 3:01:48 PM (MST) and 3/14/2016 3:01:00 PM (MST)

For Clinic Use:

*Use eScreen Scheduled Event Account*

Confirmation #:

AI150805098U

Reason for Service:

Other

Name:

Michael Clampett

eScreen Acct #:

124610-0
Accredited Drug Testing, Inc./Health
Screenings USA (Customer)

Account Type:

National Account

Services to be performed:
Non-DOT Physical

Additional Requirements/Notes:

Bill services to :
eScreen, Inc.

I authorize the above named clinic to release my results of the medical services listed on this Passport to
eScreen.

PO Box 25902
Overland Park, KS 66225

Signature:

Date:

Contact eScreen Client Services with questions: (800) 881-0722 opt. 5

Clinic #:

38335

eScreen Account #:

124610-0

Confirmation #:

AI150805098U

AI150805098U
AI150805098U

Applicant/Employee Name:

Clampett, Michael

Confirmation Number:

AI150805098U

eScreen Account Info:

124610-0

eScreen Site ID:

38335 - Yampa Works Occupational Health

Please Note: The information on this fax coversheet is specific to a single event. To ensure timely and accurate
reimbursement for the services, please use this coversheet to fax information only for the applicant referenced above.

Clinic Instructions:
This ePassport is your clinic's authorization to perform the Health-eScreen medical service(s) listed.
Regardless of whether or not these services are in your contract agreement, your clinic will be reimbursed for the
services performed as results are received at eScreen.
Please refer to the component checklist provided below to ensure all medical services are completed per the
instructions. If your location is installed with the eScreen123 system, please be sure to check this event into the
eScreen123 software.
If any Health-eScreen services are requested in addition to the services listed, please call 1-800-881-0722, option 5
for approval/direction.
Please upload completed documents to the donor's event in the eScreen123 follow-up tab or fax completed
documents to 913-234-4507. Please fax ORIGINAL FORMS ONLY. Copies/carbons/scanned images/highlights are often
illegible upon receipt.

Please follow standard protocol unless specified for the services listed below.
[]

Non-DOT Physical - The NonDOT exam is now electronic in ePhysical. If you are unable to perform the service
electronically follow the instructions below to prevent delays for this event: Use passport forms for the exam
Confirm all sections of the form are complete, including: Applicants name/Demographic information Height
Weight Pulse Blood pressure Vision (visual acuity/color/Monovision/Horizontal field of Vision) U/A Dip
Provider signature at the bottom Hearing (whisper test) Physical Examination

Clinic Instructions Page 1

Of

AI150805098U
AI150805098U

Applicant/Employee Name:

Clampett, Michael

Confirmation Number:

AI150805098U

eScreen Account Info:

124610-0

eScreen Site ID:

38335 - Yampa Works Occupational Health

Please Note: The information on this fax coversheet is specific to a single event. To ensure timely and accurate
reimbursement for the services, please use this coversheet to fax information only for the applicant referenced above.

Clinic Instructions:
This ePassport is your clinic's authorization to perform the Health-eScreen medical service(s) listed.
Regardless of whether or not these services are in your contract agreement, your clinic will be reimbursed for the
services performed as results are received at eScreen.
Please refer to the component checklist provided below to ensure all medical services are completed per the
instructions. If your location is installed with the eScreen123 system, please be sure to check this event into the
eScreen123 software.
If any Health-eScreen services are requested in addition to the services listed, please call 1-800-881-0722, option 5
for approval/direction.
Please upload completed documents to the donor's event in the eScreen123 follow-up tab or fax completed
documents to 913-234-4507. Please fax ORIGINAL FORMS ONLY. Copies/carbons/scanned images/highlights are often
illegible upon receipt.

Please follow standard protocol unless specified for the services listed below.

BILLING INFORMATION:
Invoices for services must include the eScreen account information and SSN/ID or confirmation number (as
listed above) for the patient. Direct all invoices to eScreen at:
eScreen, Inc.
Attn: Accounts Payable
PO Box 25902
Overland Park, KS 66225-5902
Incomplete medical service forms will not be reported, and the reimbursement will not be issued until
all required information has been received by eScreen.
If you have any questions, please contact eScreen at 1-800-881-0722, option 5

Clinic Instructions Page 2

Of

Clinic #: 38335

eScreen Examination
Account #: 124610-0
Medical
Report

Employer Name:

Confirmation #: AI150805098U
Clinic:

Non-DOT Fitness Determination

1. APPLICANT INFORMATION
Applicant's Name (Last, First, Middle)

Reason For Test:

Birthdate

Social Security Number

Address

City, ST, Zip

Age

Gender

Driver's License #

Phone
Work:
Home:

2. Health History

Applicant completes this section, but medical examiner is encouraged to discuss with patient.
Yes No

Any illness or injury in the last 5 years?

13 Liver disease

Head/Brain injuries, disorders or illnesses?

14 Digestive problems

Seizures, epilepsy

15 Diabetes or elevated blood sugar controlled by

Eye Disorders or impaired vision (except corrective lenses)

Ear disorders, loss of hearing or balance

Heart disease or heart attack; other cardiovascular condition

Medication

Diet

Pills

Insulin

16 Nervous or psychiatric disorders, e.g., severe depression

Medication
17 Loss of, or altered consciousness
18 Fainting, dizziness

Heart surgery (valve replacement/bypass, angioplasty, pacemaker)

19 Sleep disorders, sleep apnea, loud snoring

High Blood Pressure

20 Stroke or paralysis

Medication
9

Muscular disease

21 Missing or impaired hand, arm, foot, leg, finger, toe

22 Spinal injury or disease

10 Shortness of breath

23 Chronic low back pain

11 Lung disease, emphysema, asthma, chronic bronchitis

24 Regular, frequent alcohol use

12 Kidney disease, dialysis

25 Narcotic or habit forming drug use

For any YES answer, indicate onset date, diagnosis, treating physician's name, address, and any current limitation. List all medications (including over-the-counter medications) used regularly or recently.

I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination.

Applicant's Signature
Medical Examiner Comments

State of Issue

Yes No

Medication

License Class
A
C
B
D
Other

Date of Exam

Date

Clinic #: 38335

eScreen
Account
#: 124610-0
TESTING (Medical
Examiner
completes
Section 3 through 8)

Employer Name:

Confirmation #: AI150805098U
Applicant Name:

3. VISION

The use of corrective lenses should be noted.

Instructions: When other than the Snellen chart is used, give test results in Snellen comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as
numerator and the smallest type read at 20 feed as a denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If applicant habitually wears
contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious.
Acuity

Uncorrected

Corrected

Horizontal Field of Vision

Right Eye

20 /

20 /

Right Eye:

Left Eye

20 /

20 /

Left Eye:

Applicant can recognize and distinguish among traffic control signals and
devices showing standard red, green, and amber colors?
Yes

No

Applicant meets visual acuity requirement only when wearing:

Corrective Lenses

Both Eyes

20 /

Monocular Vision:

20 /

Yes
4. HEARING

No

Check if hearing aid used for tests.

Instructions: To convert automatic test results from ISO to ANSI, -14 dB from ISO for 500 Hz, -10 dB for 1000 Hz, -8.5 dB for 2000 Hz. To average, add the readings for 3 frequencies tested and divide by 3.
Numerical readings must be provided.

Complete either Section A or B

a) Record distance from individual at which

forced whispered voice can first be heard.

Right Ear

Left Ear

feet

feet

Right Ear

b) If audiometer is used, record

hearing loss in decibels.
(acc. To ANSI Z24.5-1951)

50 Hz

Left Ear
1000 Hz

Average:
5. BLOOD PRESSURE / PULSE RATE
Blood Pressure

Numerical readings must be recorded.

Systolic

Diastolic

Pulse Rate:

Regular

Irregular

Record Pulse Rate:

6. LABORATORY & OTHER FINDINGS

Numerical readings must be recorded.

Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying medical problem.
Urine Specimen

Sp.Grav.

Other testing (Describe and record):

Protein

Blood

Sugar

2000 Hz

50 Hz

Average:

1000 Hz

2000 Hz

Clinic
#: 38335
Employer
Name:

eScreen Account #: 124610-0

Applicant Name:

Confirmation #: AI150805098U

7. PHYSICAL EXAMINATION

Height:

Weight:

BMI:

Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below.
BODY SYSTEM

CHECK FOR:

1. General Appearance

Marked overweight, tremor, signs of alcoholism, problem drinking, or drug abuse.

2. Eyes

Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle imbalance, extraocular movement, nystagmus, exophthalmos, strabismus uncorrected by corrective lenses,
retinopathy, cataracts, aphakia, glaucoma, macular degeneration.

3. Ears

Middle ear disease, occlusion of external canal, perforated eardrums.

4. Mouth & Throat

Irremediable deformities likely to interfere with breathing or swallowing.

5. Heart

Murmurs, extra sounds, enlarged heart, pacemaker, implantable defibrillator.

6. Lungs and Chest

Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezing or alveolar rales, impaired respiratory function, dyspnea, cyanosis. Abnormal findings on
physical exam may lead to pulmonary tests or a chest x-ray.

7. Abdomen and Viscera

Enlarged liver, enlarged spleen, masses, bruits, hemia, significant abdominal wall muscle weakness.

8. Vascular System

Abnormal pulse and amplitude, carotid or arterial bruits, vericose veins.

9. Genito-urinary System

Hernias

10. Extremities

Loss or impairment of leg, foot, toe, arm, hand, finger. Perceptible limp, deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia. Insufficient grasp & prehension in upper limb to
maintain steering wheel grip. Insufficient mobility & strength in lower limb to operate pedals properly.

YES NO

11. Spine, Musculoskeletal Previous surgery, deformities, limitation of motion, tenderness.

12. Neurological

Impaired equilibrium, coordination or speech pattern; paresthesia, asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal patellar & Babinski's reflexes, ataxia.

Examiner Comments:

8. Final Disposition & Certification

PASS

I have examined the individual named above and to the best of my knowledge, he/she is in good physical and mental health and is able to function in his/her profession in full capacity.

FAIL

I have examined the individual named above and to the best of my knowledge, he/she is not in good physical and/or mental health and is not able to function in his/her profession in full capacity.
Medical Examiner's Signature:
Medical Examiner's Name (print):
Address:
Telephone Number: