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

ATTACHMENT B
Disclosure of Prescription and Over-the-Counter Drugs
INSTRUCTIONS FOR EMPLOYEES IN SAFETY SENSITIVE POSITIONS
Attachment B forms are required by Orange County Transportation Authority (OCTA) for employees in Safety
Sensitive Positions.
1. If you are disclosing the use of a new prescription drug, complete "Employee” section of this form on Page 1, have
your doctor complete “Physician” section, and forward to your supervisor.
2. If you are disclosing a prescription drug renewal, complete “Employee” section of this form on Page 1, attach a copy
of your prescription renewal label, and forward to your supervisor.
3. If you are disclosing the use of over-the-counter medications, complete all of Page 2.
PRESCRIPTION DRUGS
To Be Completed by Physician
I, am aware of the job duties of ,
Physician’s Name Employee’s Name
who is a at Orange County Transportation Authority. I have
Employee’s Position/Job Title
prescribed for such employee the medication described below on .
Please print legibly.
Name of Medication:
Dosage:
Duration to be Taken:
Condition Medication is Being Used to Treat:
It is my opinion that, if taken in accordance with the above directions, the medication should not
materially impair the employee’s ability to perform his/her job competently and safely.
Physician’s Signature Physician’s Telephone Number
Physician’s Printed Name Date
TO BE COMPLETED BY EMPLOYEE
I hereby authorize Orange County Transportation Authority to obtain information from my physician about this medical
authorization. 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 for work.
Additionally, I understand that on-going or periodic use of prescription drugs and over-the counter medications, vitamins,
and herbs require an Attachment B form, which must be re-submitted annually each January.
Employee’s Signature Employee’s Work Location and Supervisor
Employee’s Printed Name Date
Date Supv. Received:
FOR OCTA USE ONLY
Received by:
Date HR Received: Received by:
HR: Approved Not Approved Supervisor Notified:
Date: Time:
HR-ELR-013.doc (04/19/01) Page 1 of 2
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