DATE: ………………

Medical Examination for Alcohol

OCCUPATIONAL HEALTH CENTER

To be filled by Employee (in Capital letters)

Name................................................................. Department: PRESS/ DESPATCH ……………………

Designation: ……………………………………… Employee number..................Place...........................

Date..................... Time.................Hrs

I confirm that I am not under the influence of Alcohol.

Signature

TO BE FILLED BY MEDICAL OFFICER:

1.Clinical Examination:

2a. Breath Analyser Result Negative/Positive

(Reading to be indicated in writing)

2b. If found positive …………………………………. %BAC. TIME: ……….

3. Result of 2nd Test at…………… hrs ………………%BAC. TIME………….

Remarks: He/She is not under/under the influence of alcohol at present

Signature of Witness
Signature of Medical Officer
Time: ……………....
Time: ……………….
Name and Designation
Name of Medical Officer
……………………………………….
……………………………………………….