Information

  • Affected employee

  • Conducted on

  • Prepared by

  • Location

Medical Treatment Waiver

  • Last 4 Digits of Social Security #

  • Position

  • Date and Time of Incident

  • Date of Birth

  • Office Location

  • 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

  • Date

  • Foreman Signature

  • Date

  • EHS Specialist

  • Date

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.