Prescription and Over-the-Counter Medications Tool Kit ... - Home

Release To Work Form 1C1
Maryland Transit Administration
OVER-THE-COUNTER AND PRESCRIPTION
DRUG POLICY
Rev No. Issue Date: Supercedes Procedure/Bulletin No. Page 7 of 7
RELEASE TO WORK FORM FOR PRESCRIPTION MEDICATIONS
Form 1C1- 2 sides (02/01/02)
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Employee’s Section:
Printed Name ________________________________________ SS# ____________________
Employee’s MTA Safety-Sensitive Job Function – check those that apply.
Υ Operate a transit bus or train.
Υ Operate a non-revenue service vehicle requiring a commercial driver’s license (e.g., trucks over 25,000 lbs.).
Υ Control the dispatch or movement of transit buses or trains.
Υ Maintain/repair transit buses or trains or the electro-mechanical systems controlling train movement.
Υ Carry a firearm for security purposes.
Υ Supervisor whose duties require the performance of any of the above functions. (Check those that apply.)
Medication(s) currently being taken ___________________________________________________________________
I attest that the foregoing information is complete and correct.
Employee Signature ____________________________________ Date ____________________
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Physician’s Section:
As the attending physician, I have prescribed the following medication(s) to be taken from ______ to ________.
_________________________________________ ___________________
Name of Medication Dosage
_________________________________________ ___________________
Name of Medication Dosage
(PLEASE CHECK ONE OF THE FOLLOWING.)
! Employee may not perform safety-sensitive duties while taking this medication. (Employee – give form to your supervisor.)
! Employee released to perform safety-sensitive duties while taking this medication. (Employee – keep form on your person
while at work.)
______________________________________________ ______________________
Physician’s Printed Name Telephone No.
______________________________________________ ______________________
Signature Date
Reviewed By: (Signature) (Date)
Human Resources Department Management __________________________________________
Bus Operations Management __________________________________________
Light Rail Operations Management __________________________________________
Metro Rail Operations Management __________________________________________
Safety and Risk Management __________________________________________
_______________________________ __________________________________________
Approved By:
Virginia White
(Print Name)
(Signature)
January 25, 2002
(Date)
Acting Administrator
(Title)