GO DIGITAL TODAY Convert your paper checklists into digital forms
Scan this QR code to use this paper checklist on your smartphone or tablet. Visit www.iauditor.com
Medical Treatment Waiver
Date and Time of Incident
By signing this form, I declare that medical treatment is not necessary for the injury/incident/illness from the aforementioned date. I elect not to receive medical treatment at this time. I also understand that if I decided to seek medical treatment, at any time, I must first inform the Foreman and the Safety Department prior to seeking medical treatment.
I have read and understand the above Agrodrain Medical Treatment Waiver and agree to abide by the procedures set forth.
Agrodrain: Medical Waiver Form
Medical waiver form for injured employees who do not feel they need medical attention at the time.
Download this checklist to iAuditor to edit, save, share, and implement your processes.
Print as PDF
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended
take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or
or other applicable laws. You should also seek your own professional advice to determine if the use of such
permissible in your workplace or jurisdiction.