Follow-Up Visit for Occupational Exposure Form

Document follow-up visits for employees who have experienced occupational exposure.

Employee Full Name *

Date of Birth *

Date of Original Exposure *

Date of Follow-Up Visit *

Type of Exposure (e.g., chemical, biological, physical) *

Location of Exposure *

Symptoms Reported by Employee

Assessment of Symptoms by Physician

Tests Conducted

Results of Tests (if available)

Recommended Treatment/Intervention

Next Steps/Follow-Up Plan

Physician/Health Professional Name *

Signature of Employee