Information
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Affected employee
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Conducted on
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Prepared by
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Location
Medical Treatment Waiver
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Last 4 Digits of Social Security #
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Position
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Date and Time of Incident
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Date of Birth
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Office Location
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By signing this form, I declare that medical treatment is unnecessary and 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 also agree to accept the Chaparral Energy, LLC, restricted work offer if the treating physician later does not release me for full duty at the time of treatment. In addition, the Light Duty Offer will be read, fully completed, and signed.
I have read and understand the above Medical Treatment Waiver and agree to abide by the procedures set forth. -
Employee Signature
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Date
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Foreman Signature
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Date
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EHS Specialist
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Date
