Medical Surveillance Program Consent & Authorization Form

Medical Surveillance Program Consent & Authorization Form

Occupational medical surveillance is a critical component of workplace safety programs, especially for employees exposed to hazardous materials, chemicals, noise, or other occupational health risks. This Medical Surveillance Program Consent & Authorization Form template provides a complete, OSHA-compliant framework for documenting employee consent, HIPAA authorization, and notification preferences for workplace medical monitoring programs.

Built for Occupational Health & Safety Teams

This template is designed specifically for healthcare providers, occupational health clinics, safety managers, HR departments, and employers who need to establish or maintain medical surveillance programs for at-risk workers. Common use cases include:

• Baseline medical testing for new employees entering hazardous roles
• Periodic monitoring programs for ongoing exposure assessment
• OSHA-mandated surveillance for specific substances (lead, asbestos, noise, respirator use, bloodborne pathogens)
• HIPAA-compliant authorization for sharing medical information with employers
• Documentation of consent for medical examinations and procedures
• Employer notification protocols while protecting employee privacy

What This Form Captures

This comprehensive template collects all essential information for establishing a compliant medical surveillance program:

• Employee and employer identification details
• Specific exposure types and job hazards
• Medical surveillance program requirements
• Baseline and periodic testing schedules
• Informed consent for medical examinations
• HIPAA authorization with specific disclosure limits
• Employer notification preferences
• Employee rights and confidentiality protections
• Legal acknowledgments and signatures

The form balances legal compliance with clarity, ensuring employees understand their rights while providing healthcare providers and employers with the authorizations needed to conduct effective monitoring programs.

OSHA Compliance & Privacy Protection

This template is structured to meet OSHA medical surveillance requirements while maintaining strict HIPAA privacy standards. It clearly defines what information can be shared with employers (fitness for duty, exposure levels, recommendations) versus what remains confidential (specific diagnoses, detailed medical findings). This distinction is critical for legal compliance and employee trust.

Streamline with Paperform & Papersign

Create a professional, compliant medical surveillance consent process with Paperform's conditional logic that adapts questions based on exposure type and surveillance requirements. Add Papersign (papersign.com) to capture secure electronic signatures from both employees and healthcare providers, creating a complete digital consent and authorization workflow that maintains proper documentation and audit trails.

For organizations managing multiple facilities or surveillance programs, use Stepper (stepper.io) to automate follow-up reminders for periodic testing, route completed forms to appropriate medical staff, update employee health records, and notify safety managers when surveillance is complete—all while maintaining strict confidentiality protocols.

This template is ideal for occupational health physicians, industrial hygienists, EHS managers, HR directors, manufacturing facilities, healthcare organizations, construction companies, and any employer subject to OSHA medical surveillance requirements who need a compliant, professional solution for documenting employee consent and authorization.