Scan this barcode into eScreen123®

*AI4539048749*
AI4539048749

Instructions for Angela Martin

This order must be completed by: • You are required to take a photo ID,
this ePassport, and all documents with
which it printed.
5/5/2021 8:16 PM (ET)
• If you are under 18, a parent or legal
Note: Completion time displayed does not mean that guardian may be required in order for
the service provider is open until the time shown. services to be performed. Verify with
the service provider before arriving.
Please proceed to the following location:
Concentra Medical Center - Brighton
7960 GRAND RIVER RD
STE 100
BRIGHTON, MI 48114
Phone: 810-225-9800 Fax: 810-225-9807
Note: Please call service provider for operational hours and to schedule
an appointment or visit the service provider’s website for hours of operation.

Instructions for Service Provider

Providers with eScreen123 must scan ePassport into eScreen123. Use eScreen Scheduled Event Account.
Bill services to: eScreen, Inc., PO Box 25902, Regulation: NON-DOT
Overland Park, KS 66225 Reason for Test: Pre-employment
Services(1): 1. Urine Collection - 1303 -
9DSP/EXP OPI/OXY100/PHN
Account: 172477-1 (1303)
FCA US LLC - FCA US LLC Chrysler Corporation
Reason for Service: Pre-employment
Account Type: National Account
Services(2): 1. STS - FCA - Chrysler Custom
Physical - Concentra or Acension
Only
Participant ID: 2. Grip Strength Evaluation

© 2019 Abbott. All rights reserved. All trademarks referenced are trademarks of either the Abbott group of companies or their respective
owners.
Clinic #: 15104 eScreen Account #: 172477-1 Confirmation #: AI4539048749

AI4539048749
Applicant/Employee Name: Martin, Angela
Confirmation Number: AI4539048749
eScreen Account Info: 172477-1 AI4539048749
eScreen Site ID: 15104 - Concentra Medical Center - Brighton
Please Note: The information on this document is specific to a single event. To ensure timely and accurate
reimbursement for the services, please use this information only for the applicant referenced above.

Clinic Instructions:
If your location is installed with the eScreen123 system, please be sure to check this event into the eScreen123
software.

This ePassport is your clinic's authorization to perform the Health-eScreen occupational health service(s) listed.
Services completed in eScreen123 are already in our system and don’t require faxing or uploading of documents. For
paper/handwritten forms completed outside of eScreen123, please upload completed documents to the donor's event in the
eScreen123 Follow-Up tab or fax completed documents to 913-234-4507. Please fax ORIGINAL FORMS ONLY.
Copies/carbons/scanned images/highlights are often illegible upon receipt.

Your clinic will be reimbursed for the requested services performed. If your clinic is contracted for the services, you will be
reimbursed at your contracted rate. If you are not contracted, please invoice eScreen directly.

Please refer to the component checklist provided below to ensure all occupational health service(s) are completed per the
instructions.

If any occupational health service(s) are requested in addition to the services listed, please call 1-800-881-0722, option 5 for
approval/direction.

Please follow standard protocol unless specified for the services listed below.

[] STS - FCA - Chrysler Custom Physical - Concentra or Acension Only - Dipstick U/A and Snellen vision are
included in the physical exam The provider needs to complete the Chrysler Physical Summary Page: PQ=
Qualified PQX= Qualified with Limitations. The provider then needs to include the applicable limitation codes
from the document. Please ensure Dynamometer results are noted under Upper Extremities. ALL paperwork
needs to be faxed back to eScreen.

[] Grip Strength Evaluation - Please complete the form attached to the passport

Clinic Instructions Page 1 Of 2

 AI4539048749
Applicant/Employee Name: Martin, Angela
Confirmation Number: AI4539048749
eScreen Account Info: 172477-1 AI4539048749
eScreen Site ID: 15104 - Concentra Medical Center - Brighton
Please Note: The information on this document is specific to a single event. To ensure timely and accurate
reimbursement for the services, please use this information only for the applicant referenced above.

Clinic Instructions:
If your location is installed with the eScreen123 system, please be sure to check this event into the eScreen123
software.

This ePassport is your clinic's authorization to perform the Health-eScreen occupational health service(s) listed.
Services completed in eScreen123 are already in our system and don’t require faxing or uploading of documents. For
paper/handwritten forms completed outside of eScreen123, please upload completed documents to the donor's event in the
eScreen123 Follow-Up tab or fax completed documents to 913-234-4507. Please fax ORIGINAL FORMS ONLY.
Copies/carbons/scanned images/highlights are often illegible upon receipt.

Your clinic will be reimbursed for the requested services performed. If your clinic is contracted for the services, you will be
reimbursed at your contracted rate. If you are not contracted, please invoice eScreen directly.

Please refer to the component checklist provided below to ensure all occupational health service(s) are completed per the
instructions.

If any occupational health service(s) are requested in addition to the services listed, please call 1-800-881-0722, option 5 for
approval/direction.

Please follow standard protocol unless specified for the services listed below.

BILLING INFORMATION:
Invoices for services must include the eScreen account information and SSN/ID or confirmation number (as
listed above) for the patient. Direct all invoices to eScreen at:
eScreen, Inc.
Attn: Accounts Payable
PO Box 25902
Overland Park, KS 66225-5902

Incomplete medical service forms will not be reported, and the reimbursement will not be issued until
all required information has been received by eScreen.
If you have any questions, please contact eScreen at 1-800-881-0722, option 5

Clinic Instructions Page 2 Of 2

Clinic #: 0 eScreen Account #:

Chrysler Physical Summary

Donor Name:

Donor SSN:

Physician’s Findings:

PQ (Physically Qualified)

PQX

If PQX, Exception Codes :

Deferred: A new hire candidate is placed in a deferred status when there is a medical condition that
requires additional information from the treating specialist or family physician to determine if the employee can safely
work in a manufacturing or warehouse setting. Examples are not limited to elevated blood pressure, elevated blood sugar,
medication that can impair function or the ability to safely work, or a physical condition that requires specific limitations
and additional documentation is necessary to determine if or what PQX is necessary.

Fax the following documents to 913 – 234 – 4507

REQUIRED
• Physical Summary (this document)
• Chrysler‐specific Exam paperwork (completely filled‐out)
• Applicant Instructions & Authorization Letter (signed by applicant)

WHEN APPLICABLE
• Physician’s Note (when applicable)

NOTE: It is the responsibility of the clinic and the assigned physician to ensure that all “Required” and
“When Applicable” documents are completely filled‐out prior to being sent to eScreen. If any field is left
blank upon receipt of the physical – the clinic will be responsible for correcting this issue in a timely
manner.

Attention Clinic: Please fax results to eScreen913 -234- 4507

Chrysler Physical Summary & Cover Sheet

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Clinic #: 0 eScreen Account #:

FORM PURPOSE: Applicant Instructions and Authorization

EMPLOYER: Chrysler Group LLC

Applicant,

Please read this document prior to visiting the clinic to submit to a physical.

Instructions:
On the first page of your Chrysler Corporation Physical, you must complete the HEALTH
HISTORY section in its entirety. Leaving any items blank may result in a delay in reporting
results to Chrysler. Also, you must complete the “Authorization” section and provide to the
physician.

Before leaving the clinic, please review the physical with the physician to ensure all components
are completed. If any items were not done, this could result in a need for you to return to the
clinic and delay the completion of the physical.

Authorization:
Should additional documentation need to be provided by my personal physician or any other
physician; I authorize the Clinic to provide the copy of this Physical exam and any rel evant
medical documents such as previous Physician's note to eScreen.

Applicant Name:

Applicant Signature: Date:

Chrysler_Applicant Instructions Authorization

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eScreen-Chrysler Physical Exam Form Page 4 of 8

Clinic #: 0 eScreen Account #:

Form Purpose: Physician Guidance Regarding PQX Code Listing

EMPLOYER: Chrysler Group LLC

Preplacement Physical Exam Guidelines

Physician,

The purpose of a preplacement evaluation is to ensure that the person examined does not
have any medical condition that may be aggravated by the job duties or that may affect the
health and safety of others. The critical determinants in this decision-making process are the
person’s health and the job itself. The primary obligation is to the health of the worker.

The essential functions of the job include standing or walking for 8 to 10 hours each day;
frequent bending, stooping, reaching and lifting up to 40 pounds; ability to work in hot and/or
cold environments; and the ability to work safely around heavy equipment or manufacturing
machinery.

If after obtaining a careful history and completing a physical exam, there are no indicators that
the person cannot perform the essential duties of the job without accommodation, there is no
need to perform a test to determine the person’s lifting capacity.

On the other hand, if the person gives a history of a condition that might be aggravated by
lifting, as in prior back injuries, or if the exam reveals any such condition, the examining
physician may request whatever history or information from the personal physician that is
needed to clarify functional capabilities. Although exact musculoskeletal capacity may be
difficult to ascertain, the physician’s best judgment, taking into account the history, physical
exam and any additional information obtained, should be used to determine restrictions.

The PQX Code Listing is on the following 3 pages

Attention Clinic: Please fax results to eScreen 913 -234- 4507

Chrysler_PhysicalExamGuidelines and PQX Code Listing
Page 5 of 8
Clinic #: 0 eScreen Account #:
Description Code Description Code
Condition Not Compatible With Work 190 No Pushing Or Pulling E00
PQX, Not placed in plant 191 No Pushing Or Pulling Over 5# E01
Neck, No Flexion/Extension A00 No Pushing Or Pulling Over 10# E02
Neck, Flexion/Extension Less Than 33% Of A01 No Pushing Or Pulling Over 15# E03
Neck, Flexion/Extension Less Than 66% Of A02 No Pushing Or Pulling Over 20# E04
No Neck Rotation A04 No Pushing Or Pulling Over 25# E05
Neck, Rotation Less Than 66% Of Shift A05 No Pushing Or Pulling Over 5# Left E06
Neck, Rotation Less Than 33% Of Shift A06 No Pushing Or Pulling Over 5# Right E07
Hand, No Gripping B00 No Pushing Or Pulling Over 10# Left E08
Hand, No Gripping Right B01 No Pushing Or Pulling Over 10# Right E09
Hand, No Gripping Left B02 No Pushing Or Pulling Over 15# Left E10
Hand, No Wide Gripping B03 No Pushing Or Pulling Over 15# Right E11
Hand, No Wide Gripping Right B04 No Pushing Or Pulling Over 20# Left E12
Hand, No Wide Gripping Left B05 No Pushing Or Pulling Over 20# Right E13
Hand, No Pinch Gripping B06 No Pushing Or Pulling Over 25# Left E14
Hand, No Pinch Gripping Right B07 No Pushing Or Pulling Over 25# Right E15
Hand, No Pinch Gripping Left B08 No Pushing Or Pulling Right E16
Wrist, No Twist B09 No Pushing Or Pulling Left E17
Hand, No Use Of Control Buttons Right B10 Hand, No Use Of Right F00
Limit Air Tools W/ Torque <37Ib Right B11 Hand, No Use Of Left F01
Hand, Must Use Antivibratory Glove Right B12 Hand, No Use Of The Right Thumb G00
Hand, No Use Of Vibratory Tools Right B13 Hand, No Use Of Left Thumb G01
Limit Vibratory Tools Right B14 Hand, No Use Of Right Index Finger G02
Arm, No Use Of Right B15 Hand, No Use Of The Left Index Finger G03
Arm, No Use Of Left B16 Hand, No Use Of Right Middle Finger G04
Wrist, Twist Left Less Than 66% Of Shift B17 Hand, No Use Of Left Middle Finger G05
Hand, No Use Of Control Buttons Left B18 Hand, No Use Of Right Ring Finger G06
Limit Air Tools W/ Torque <37Ib Left B19 Hand, No Use Of The Left Ring Finger G07
Hand, Must Use Antivibratory Glove Left B20 Hand, No Use Of The Right Little Finger G08
Hand, No Use Of Vibratory Tools Left B21 Hand, No Use Of The Left Little Finger G09
Limit Vibratory Tools Left B22 Back, No Bend/Twist H00
Hand, Wide Gripping Left Less Than 66% O B23 Back, Bending Less Than 33% Of Shift H01
Hand, Wide Gripping Left Less Than 33% O B24 Back, Bending Less Than 66% Of Shift H02
Hand, Use Control Buttons Left< 33% Of S B25 Leg, No Stooping Or Squatting I00
Hand, Use Control Buttons Left< 66% Of S B26 Leg, Stooping Or Squatting < 33% Of Shif I01
Hand, Use Control Buttons Right < 33% Of B27 Leg, Stooping Or Squatting < 66% Of Shif I02
Hand, Use Control Buttons Right < 66% Of B28 Leg, Must Keep Elevated J00
Hand, Use Vibratory Tools Left < 33% Of B29 Leg, Must Keep Left Elevated J01
Hand, Use Vibratory Tools Left < 66% Of B30 Leg, Must Keep Right Elevated J02
Hand, Use Vibratory Tools Right < 33% Of B31 Foot, Must Use Special Shoe J03
Hand, Use Vibratory Tools Right < 66% Of B32 Leg, No Kneeling Or Crawling K00
Wrist, Twist Left Less Than 33% Of Shift B33 Leg, Kneeling Or Crawling Less Than 33% K01
Elbow, Twist Left Less Than 33% Of Shift B34 Leg, Kneeling Or Crawling Less Than 66% K02
Elbow, Twist Right Less Than 66% Of Shif B35 No Standing Work L00
Elbow, Twist Right Less Than 33% Of Shif B36 Standing Work Less Than 33% Of Shift L01
Hand, Gripping Left Less Than 66% Of Shi B37 Standing Work Less Than 66% Of Shift L02

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Hand, Gripping Left Less Than 33& Of Shi B38 Must Have Sit/Stand Option L04
Hand, Gripping Right Less Than 66% Of Sh B39 No Walking M00
Hand, Gripping Right Less Than 33% Of Sh B40 Requires The Assistance Of A Cane M01
Hand, Pinch Gripping Left < 66% Of Shift B41 Requires The Assistance Of Crutches M02
Hand, Pinch Gripping Left < 33% Of Shift B42 Walking Less Than 33% Of Shift M03
Hand, Pinch Gripping Right < 66% Of Shif B43 Walking Less Than 66% Of Shift M04
Hand, Pinch Gripping Right < 33% Of Shif B44 No Climbing N00
Hand, Use Control Buttons < 66% Of Shift B45 Leg, Climbing Less Than 66% Of Shift N01
Hand, Use Control Buttons < 33% Of Shift B46 No Elevated Platforms/ Next To Open Pit N02
Hand, Wide Gripping Right 66% Of Shift B47 Leg, Climbing Less Than 33% Of Shift N03
Hand, Wide Gripping Right < 33% Of Shift B48 No Work That Requires Vision P00
Elbow, No Twist Right B49 No Work Tht Requires Near Vision P01
Elbow, No Twist Left B50 No Work That Requires Far Vision P02
Elbow, Twist Left Less Than 66% Of Shift B51 No Work That Requires Vision In Both Eye P03
Wrist, Twist Right Less Than 33% Of Shif B52 No Work That Requires Color Perception P04
Wrist, Twist Right Less Than 66% Of Shif B53 Must Wear Corrective Lens P05
Hand No Gripping With Wrist Flexion Righ B54 No Night Driving P06
Hand No Gripping With Wrist Flexion Left B55 Wear Plant Approved Shade 2 Tinted Glass P07
Shoulder, No Reaching Above C00 No Work That Requires Hearing R00
Shoulder, No Reaching Above Right C01 No Work Requiring Conversational Speech R01
Shoulder, No Reaching Above Left C02 Must Wear Hearing Aids R02
Shoulder, Reach Above Right < 33% Of Shi C03 No Speech Ability R03
Shoulder, Reach Above Right < 66% Of Shi C04 Limited Ability To Speak R04
Shoulder, Reach Above Left < 33% Of Shif C05 No Exposure To Noise > 85 DB R05
Shoulder, Reach Above Left < 66% Of Shif C06 Avoid Dust And Smoke S00
Shoulder, Limited Reaching Right C07 Avoid Fumes S01
Shoulder, Limited Reaching Left C08 Avoid Exposure To Metal Working Fluids S02
Shoulder, Reach Left Less Than 33% Of Sh C09 Limit Exposure To Metal Working Fluids S03
Shoulder, Reach Left Less Than 66% Of Sh C10 No Use Of SCBA S04
Shoulder, Reach Right Less Than 33% Of S C11 No Use Of Negative Pressure Respirator S05
Shoulder, Reach Right Less Than 66% Of S C12 Must Have Power Air Purified Respirator S06
Shoulder, No Reaching Right C13 Must Wear Respirator S07
Shoulder, No Reaching Left C14 No Exposure To EMF > 1 Gauss S08
No Lifting Over 5# Right D00 No Spray Painting or Paint Booth Work S09
No Lifting Over 5# Left D01 No Exposure to Isocyanates S10
No Lifting Over 5# D02 Must Wear Gloves T00
No Lifting Over 10# Right D03 Avoid Skin Contact With Solvents T01
No Lifting Over 10# Left D04 Avoid Skin Contact With Oil And Grease T02
No Lifiting Over 10# D05 Requires Urgent Bathroom Privileges U00
No Lifting Over 15# Right D06 Must Wear Brace/Splint While Working U01
No Lifting Over 15# Left D07 No Work Beyond Hours Of Regular Shift U02
No Lifting Over 15# D08 Local Travel Only U03
No Lifting Over 20# Right D09 Avoid Exposure To Excessive Heat U04
No Lifting Over Over 20# Left D10 Avoid Exposure To Excessive Cold U05
No Lifting Over 20# D11 No Work In Confined Spaces U06
No Lifting Over 25# Right D12 No Driving Or Operating Equipment V00
No Lifting Over 25# Left D13 No Driving Without Corrective Lenses V01

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No Lifting Over 25# D14 No Driving Of Power Industrial Vehicles V02

No Lifting Over 30# Right D15 No Driving Of Company Vehicles V03
No Lifting Over 30# Left D16 No Operating Of Moving Machinery V04
No Lifting Over 30# D17 No Operating Of Overhead Cranes V05
Lifting 10# Less Than 33% Of Shift D18
Lifting 10# Less Than 66% Of Shift D19
Lifting 10# Left Less Than 33% Of Shift D20
Lifting 10# Left Less Than 66% Of Shift D21
Lifting 10# Right Less Than 33% Of Shift D22
Lifting 10# Right Less Than 66% Of Shift D23
Lifting 15# Left Less Than 33% Of Shift D24
Lifting 15# Left Less Than 66% Of Shift D25
Lifting 15# Right Less Than 33% Of Shift D26
Lifting 15# Right Less Than 66% Of Shift D27
Lifting 15# Less Than 33% Of Shift D28
Lifting 15# Less Than 66% Of Shift D29
Lifting 20# Less Than 33% Of Shift D30
Lifting 20# Less Than 66% Of Shift D31
Lifting 20# Left Less Than 33% Of Shift D32
Lifting 20# Left Less Than 66% Of Shift D33
Lifting 20# Right Less Than 33% Of Shift D34
Lifting 20# Right Less Than 66% Of Shift D35
Lifting 25# Less Than 33% Of Shift D36
Lifting 25# Less Than 66% Of Shift D37
Lifting 25# Left Less Than 33% Of Shift D38
Lifting 25# Left Less Than 66% Of Shift D39
Lifting 25# Right Less Than 33% Of Shift D40
Lifting 25# Right Less Than 66% Of Shift D41
Lifting 30# Less Than 33% Of Shift D42
Lifting 30# Less Than 66% Of Shift D43
Lifting 30# Left Less Than 33% Of Shift D44
Lifting 30# Left Less Than 66% Of Shift D45
Lifting 30# Right Less Than 33% Of Shift D46
Lifting 30# Right Less Than 66% Of Shift D47
Lifting 5# Less Than 33% Of Shift D48
Lifting 5# Less Than 66% Of Shift D49
Lifting 5# Left Less Than 33% Of Shift D50
Lifting 5# Left Less Than 66% Of Shift D51
Lifting 5# Right Less Than 33% Of Shift D52
Lifting 5# Right Less Than 66% Of Shift D53

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Grip Strength (Hand Dynamometer) Evaluation Record

Name: ____________________ DOB: _________ ID/SSN: _________

Maximum
Measurement Measurement Measurement Measured of
#1 #2 #3 3 attempts

Right Hand

Left Hand

Percentile Rank = __________% (See Normative Grip Strength Table – Page 2)

___________________________ ___________________________
Provider Signature Date
Clinic #: 0 eScreen Account #: