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

OVER-THE-COUNTER MEDICATION
To be Completed by Employee
ATTACHMENT B
Disclosure of Prescription and Over-the-Counter Drugs
I, , am a Safety Sensitive employee. My job title is
Print/Type Name Legibly
, and my work location is .
Print/Type Job Title Print/Type Work Location
I take the following over-the-counter medications as directed* on the package as needed.
PLEASE ATTACH A COPY OF EACH LABEL FOR MEDICATIONS LISTED.
* If the medication is not taken as directed, please explain:
GENERAL PAIN RELIEF COLD/FLU MEDICATION
SINUS RELIEF VITAMINS/MINERALS/HERBS
OTHER OTHER
I understand that it is my obligation to inform Orange County Transportation Authority of any medication I
intend to take for review and determination of my eligibility to work. Additionally, I understand that ongoing
or periodic use the prescription drugs and over-the-counter medications, vitamins/herbs require
an Attachment B form, which must be resubmitted annually each January.
Employee’s Signature Date
FOR OCTA USE ONLY
Date Supv. Received: Received by:
Date HR Received: Received by:
HR: Approved Not Approved Supervisor Notified:
Date: Time:
HR-ELR-013.doc (04/19/01) Page 2 of 2