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

MEDICATION APPROVAL FORM
(For Safety-Sensitive Employees)
I. EMPLOYEE COMPLETES THIS SECTION
Employee Name ____________________________________________________ Date ______________________________
Social Security No. - - Job Title _________________________________________________
Division (check one): Meadowbrook∀ Central ∀ Mt. Ogden ∀ Timpanogos ∀ Riverside∀ Rail Service ∀
Dept. (check one): Maintenance ∀ Operations ∀ Admin. ∀
Medications I am Currently Taking:
Name Of Drug Approximate Date Prescribed Prescribing Physician
_____________________________ ______________________________ _______________________________
_____________________________ ______________________________ _______________________________
_____________________________ ______________________________ _______________________________
This information is true and correct to the best of my knowledge. I understand and will comply with the prescribed use of these medications and their
restrictions while working.
__________________________________________________________ ______________________________________
Signed Date
II. PHYSICIAN COMPLETES THIS SECTION
Please complete this form so that your patient can work in his/her Utah Transit Authority safety-sensitive job. By signing below, you
are acknowledging that you are aware of this employee’s job requirements and day-to-day responsibilities, and that the newly prescribed
medication(s) in conjunction with medication(s) currently being taken will not impair performance or endanger the safety of this
individual, coworkers, UTA customers, or the public. Please indicate below what, if any, restrictions should be placed upon the time
between when a medication is taken and the time that individual can safely and effectively perform his/her job duties. UTA’s
Prescription Drug Class list is on the back of this form.
New Medications Being Prescribed:
Name Of Drug Dosage # of Pills/Refills Date Approval Expires Restrictions/ Instructions
__________________ _______ _____________ _________________ ____________________________________
__________________ _______ _____________ _________________ ____________________________________
__________________ _______ _____________ _________________ ____________________________________
1. I have reviewed the above named UTA employee’s medical records and am familiar with the employee’s job duties. In my opinion,
this patient’s condition and the medication(s) listed above will not interfere with his/her ability to safely perform those job duties.
Comments:
2. This individual is currently under my medical supervision and was last seen on _____________________ and will be reevaluated
on _______________________________.
Signed _________________________________________________________ Dated _______________________
Please Print Name, Address and Phone Number. _____________________________________________________
_____________________________________________________
_____________________________________________________
*Please return the ORIGINAL form to the Human Resources Department
UTAH TRANSIT AUTHORITY
3600 South 700 West
Salt Lake City, UT 84130-0810
Telephone (801) 262-5626
FAX (801) 287-4555
Revised 9/00