Labor & Industries (L&I), Washington State

Benzene Chapter 296-849, WAC

Effective Date: 06/01/07

Chapter 296-849 WAC Helpful Tool: Declination Form for Nonemergency Related Medical Evaluations (Optional)

For printing For modifying

You may use this optional form to document employee decisions to decline participation in the medical evaluation process for exposure to benzene.

 

Declination Form for Nonemergency RelatedMedical Evaluations
(Optional)

 

Employer______________________________________________

I understand that because of my occupational exposure to benzene, I may be at risk for serious health effects including various blood disorders such as leukemia; an irreversible and fatal disease. I also understand that without medical examinations and tests, I may not be able to detect the onset of blood disorders.

You have given me the opportunity to receive medical examination and testing for potential health effects from benzene, at no cost to me. However, I decline to receive this medical examination and testing at this time.

I understand that by declining medical examination and testing, I continue to be at risk for leukemia and other health effects related to benzene exposure, without the benefit of early detection made possible by medical examination and testing.

I understand that I must have a medical evaluation to wear a respirator and without such an evaluation I cannot wear a respirator as part of my job. I also understand that declining to receive medical examination and testing for health effects from benzene exposures does not exclude me from receiving a separate medical evaluation for respirator use.

If, in the future, I continue to have benzene exposure and decide to receive medical examination and testing, I will be given the opportunity to receive them at no cost to me.

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Employee’s Name (Print)

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Employee’s Signature

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Date