Solutions 2009 - (Page 61) 61 Medical evaluation If you are registering for the 40-Hour Hazardous Waste Site Worker, 24-Hour Emergency Response Technician, or 24-Hour Operations Level Emergency Response courses, you must complete this form prior to the course date. If you have questions, please call (865) 974-3991 or (865) 974-2009. HISTORY OF YES Uncontrolled Hypertension ❑ Angina Pectoris ❑ Myocardial Infarction ❑ Aortic Stenosis ❑ Other Cardiac Disease ❑ Pneumothorax ❑ Asthma ❑ Chronic Respiratory Disease ❑ Phobias to Confined Spaces ❑ NO ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If yes, please explain: PHYSICAL EXAMINATION Height Weight BP Systolic BP Diastolic Pulse Respiration Heart Rate Rhythm Murmurs Lungs Medical Clearance for Hazardous Waste Training Program I have evaluated (participant’s name) and find him/her medically fit to participate in “full dress-out” using personal protective equipment, including a respirator, in the hazardous waste training program. Physician’s Signature Print Name Address City/State/Zip Telephone Number ( ) Date Participant Release I acknowledge that my enrollment in, and the nature of, hazardous material training constitutes certain inherent exposures to personal injury or property damage. I hereby hold harmless the Midwest Consortium for Hazardous Waste Worker Training and The University of Tennessee, its officers, employees, directors, and agents from any and all claims of whatever nature whether personal injury, death, and/or property loss arising from enrollment in hazardous material training. I acknowledge that the wearing and use of personal protective equipment will require additional physical exertion on my part. I acknowledge that I have discussed my participation in this activity with my physician, have answered to the best of my knowledge the questions asked by that physician concerning my health, and have received a physical examination from said physician. This agreement is binding upon me, my heirs, successors, personal representatives, and assigns. I make this agreement knowingly and voluntarily. Participant Signature Title Date Center for IndustrIal servICes (888) 763-743 • W W W. C I S . T E N N E S S E E . E D U • (615) 532-8657 http://WWW.CIS.TENNESSEE.EDU
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