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NORFOLK SOUTHERN CORPORATION FORM MED-15 (rev.

7105)
NORFOLK SOUTHE RN RAILWAY COMPANY (Item 362072) Page I of 4
MEDICAL SERVICES
THREE COMMERCIAL PLACE, NORFOLK, VA 23510-9202
^^ . Telephone (800) 552.2306 --- Fax (757) 629-2479
AuthorizationJRenort of
Medical Examination
INSTRUCTIONS FOR EMPLOYING Q €CER:
> Please complete sections A, B, C and D below and the top section of pages 2 and 3 (applicantlemployee information ) of the Form MED-25.
9 Provide applicantlempioyee with the Form Med-15 (and all other necessary forms) prior to the examination.
9 Instruct applicant/employee to read and carefully follow the Instructions on pages I and 2 of the Form Med-15.

IMPORTANT INFORMATION FOR APPLICANT/EMPLOYEE_-


Please carefully read and follow all instructions noted below.
Please complete sections E and F prior to the examination.
➢ Employee only - if returning to work from a medical absence , to expedite your return to work please call the Norfolk Southern Medical Department's toll-
free # (877) 737.0746 and complete appropriate requirements prior to your examination.
i Employee only - upon conclusion of your examination , the Medical Examiner will complete and provide to you a work Status Report form, which you must,.,
then provide to your supervisor prior to your return to service.

A. APPOINTMENT INFORMATION:
- Modical Examiner Facility Name
Appt. Date/Time Address
Phone No.

B. PURPOSE OF EXAMINATION: (Check all app cable boxes


re-placement ❑ Periodic (specify:
❑ Return to Work after medical absence ❑ Return to work after non-medical absence (e.g., furlough)
0 Fitness for Service (Please describe reason for fitness for service exam and discuss this with the employee):

❑ Federal urine dru test Cl Comp any urine drugtest ❑ Other tests s ecif : )

C. APPLICANTIEMPLOYEE INFORMATION:
Name (Print) Last First CA 4r z7g - Middle Initial
Home Address /55'.5 &41 .' S ( rL., -- city... State ' Zip
Business Phone No. Home Phone No . to 5\57 3 Date of Birth
'Social Security No. or Employee 1D No. -2 V if- 73- ;2 -4 3 V Present Occupatio
Occu ation a lied for. C,/r" ^ Prior applicant (If "Yes" give date of a lication :

D. EMPLOYER/REQUESTING DEPARTMENT INFORMATION:


Supervisor 's Name Title " - _. Department
Supervisor 's Phone No.: Location(City/State)

E. HISTORY
➢ If the purpose of your examination is Pre-placement : Please respond to "Have you ever had or do you now-have any of she following?" by
checking every item in the chart below with "Yes- or "No" or write "Don't Know".
> If the purpose of your examination its Periodic or Fitness for service : Please respond to "Since your last company physical, have you had or do
you now have any ofthe following?" by checking every item in the chart below with "Yes" or "No" or write "Don't Know".
If the purpose of your examination Is Return to work: Please respond to "For the thine period in which you were absentfrom work, have you
had or do you now have any of ehe following?" by checking every item in the chart below with "Yes" or "No" or write "Don't Know".

ITEM YES NO # ITEM YES NO


I Head/Brain injury, disorder or illness 14 .. Heart disease, surgqry. procedure or chest pain
2 Epilepsy, seizures or fits 15 blood pressure
3 Loss of consciousness, dizziness or faintin spells 16 Diabetes
4 Memo loss or excessive difficulty concentrating 17 Digestive roblems, liver or kidney disease
5 Neck injury/pain 18 Allergies (e. g., dust, coal tar, bees,.etc...)
6 Back in u 1 ain 19 Hospitalization or Sur 'cal procedure
7 Shoulder or elbow isu 1 ain 20 Tuberculosis or other infectious disease
8 Hip or knee injury/pain 21 Meep disorder (e.g., sleep a, etc...
9 Swollen or painful joints 22 Skin rash or problem
1D Numbness, weakness or paralysis 23 Asthma or other lung problem (e.g., shortness of
11 Missing or impaired hand, arm, foot, hg, f er, toe breath, cough , etc...)
12 Eye disorder or visual difficulty (except for 24 Mental or psychiatric illness (e.g., depression,
corrective lenses) anxiety, drug or alcohol de endencelabuse, etc...) ,
Ear disorder or impaired hearing or balance (except 25 Other illnesses or injuries
13
for homing aids
Applcant/Employee Name (Print):Last (1Lc:n P^a _ _-- -- First C MI FORM MED -IS (rev. yros)
Social Security No. or Employee ID No.: Page 2 of 4

E. HISTORY (CONTINUED):

PLEASE EXPLAIN ANY "YES" ANSWERS NOTED IN THE CHART ABOVE:

., PLEASE LIST ALL CURRENT MEDICATIONS:

PLEASE ANSWER THE FOLLOWING QUESTIONS:


(1) Have you ever used tobacco? Yes No Do you currently use tobacco? Yes No
If yes, how much over what period of time (e.g., # cigarette packs smoked per day and # years smoked):
(2) Do you now consumeluse or have you ever consumed/used alcohol or illicit drugs? Yes No
If yes, describe
(3) Have you ever been denied or removed from employment, or been discharged from military service for medical reasons (for
employees returning from a medical absence, answer only for period of absence)? Yes No
L
If yes, specify date of denial, removal or discharge, and medical reason:

PLEASE ANSWER THE FOLLOWING QUESTIONS ONLY IF THE PURPOSE OF YOUR EXAMINATION IS
PREPLACEMENT:
(1) Have you ever filed a claim or lawsuit because of an illness/injury? If yes, specify date, illness/injury
(2) Are you now drawing disability benefits? -Jf yes, specify. disability

F. RELEASE, VERIFICATION AND DISCLOSURE STATEMENT: (TO BE COMPLETED BY ALL EXAMINEES -


PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN BELOW)
I certify that the answers.given herein are true and complete to the best of my knowledge. I authorize release of this information to my
'employer/prospective employer and whatever investigation is deemed necessary to confirm statements contained in this report of medical
examination. If it is determined, through investigation or otherwise at any time, that any answers are untrue or misleading, or
material information is omitted, I understand my employment may be terminated, or, if applicable, my application for
employment may be rejected. If I am an applicant for employment, I acknowledge that an offer of employment, contingent on
satisfactory completion of this medical e xamina tion, a urine drug screen, and a background investigation, has been made to me.

Signature of Date signed:

G. MEDICAL EXAMINER 'S REVIEW AND SUMMARY OF HISTORY: Please comment on all "Yes" responses noted above if
initial evaluation, otherwise comment on significant interval history or note "no significant interval history":

H. PHYSICAL FINDINGS: -

HEIGHT: Ft. In. WEIGHT: Lbs. BLOOD PRESSURE: PULSE:

VISION WITH VISION WITHOUT Color Vision Field of Vision AUDIOGRAM


CORRECTION CORRECTION (Test used, Score, (Normal/Abnormal)
LEFT RIGHT LEFT RIGHT Pass/Faii) (Please attach the
completed FORM
Far 20/ Far 20/ Depth Perception MED-14)
Far 20/ Far 20/
(Test used, Score, Pass/Fail)
N20/ Near 20/ Near 20/ Near 20/