The Physical Exam Form For Work is a critical document required under Belgian workplace health and safety regulations, specifically mandated by the Code on Well-being at Work (2017). This form is used during pre-employment screenings, periodic health assessments, and return-to-work evaluations. It contains sections for recording medical history, physical examination findings, job-specific health requirements, and fitness-for-work conclusions. The document must comply with both occupational health requirements and GDPR privacy regulations, ensuring proper handling of sensitive medical information. It serves as a legal record of an employee's occupational health assessment and is particularly important for positions involving physical demands, safety-critical roles, or exposure to workplace health risks.
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1. Employee Information: Basic identification details including name, date of birth, national registration number, and contact information
2. Employer Details: Company name, department, job title/function, and work location
3. Type of Examination: Specification of examination type (pre-employment, periodic, return-to-work, etc.)
4. Job Description and Risk Factors: Brief description of job duties and associated health risks
5. Medical History: Previous medical conditions, surgeries, current medications, and family history
6. Physical Examination Results: Standard physical examination findings including vital signs, height, weight, vision, hearing
7. Job-Specific Health Requirements: Assessment of specific health requirements related to job function
8. Medical Professional's Conclusion: Final assessment and fitness-for-work determination
9. Privacy Statement and Consent: GDPR-compliant privacy notice and consent for medical data processing
10. Certification: Signatures of examining physician and date of examination
1. Specific Risk Assessments: Additional assessments for specific workplace risks (e.g., working at heights, exposure to chemicals)
2. Vaccination Status: Required for healthcare workers or positions with biological risk exposure
3. Drug and Alcohol Screening: When required by specific company policies or safety-sensitive positions
4. Ergonomic Assessment: For positions involving physical labor or specific ergonomic concerns
5. Mental Health Assessment: For high-stress positions or when specifically required
6. Follow-up Requirements: Specific instructions for future examinations or monitoring
1. Medical Test Results: Detailed results of any required medical tests (blood work, hearing tests, etc.)
2. Risk Factor Checklist: Detailed checklist of job-specific health risks and exposure factors
3. Functional Capacity Evaluation: Detailed assessment of physical capabilities relative to job requirements
4. Medical Restrictions Form: Detailed list of any work restrictions or accommodations if applicable
5. Employee Health History Questionnaire: Detailed self-reported health history form completed by employee
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