Controlled Substance Medical Exception Procedures: GBECA-E2

Name of Employee: _____________________________

Job Classification: _____________________________

Date: _____________________________

Name of Controlled Substance being used by employee: _________________________________

Physician Statement

This section must be typed and is to be completed by the employee's attending physician and must include:

1. Statement of prescription for above named employee.
2. Statement of fitness for service of employee while using the controlled substance as prescribed.

Physician Signature: _____________________________

Employee Signature: _____________________________

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For Office Use Only Date received in office: ________________

Comments: