New or Inactive Employee Medical Checklist
Medical Authorization and Release Form
Physical Exam Record Form
Medical Questionnaire Form
Audiometric/Hearing Exam Results
EKG (electrocardiogram) for persons age 40 or over or
history of cardiac issues
Blood work results
Urinalysis (not drug test) results
Copy of official vaccinations record or blood work showing
active immunity
Chest x-ray written interpretation
Blood type & RH factor
Drug test results
PHYSICAL EXAMINATION RECORD (To be completed by examining physician)
NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH (01JAN1950) SAP/EMPLOYEE NUMBER
JOB TITLE ASSIGNMENT LOCATION Age Sex
M F
VITALS VISION Female Only:
HT ► UNCORRECTED CORRECTED COLOR VISION Pregnancy Test
WT► Far Near Far Near Normal (only if required)
B/P reading(s): B B B B Abnormal Negative
R R R R Positive
L L L L
URINALYSIS (dip results if performed): Protein: Blood: Glucose:
PHYSICAL EXAMINATION►FOR ABNORMAL FINDINGS, √ BOX, MARK (L) OR (R) AND EXPLAIN BELOW
DESCRIPTION NORMAL ABN COMMENTS
Body Build (Note obesity, etc.)
APPEARANCE
Skin (Note scars, location, size)
Pupils (Note ERLA)
EYES
Fundi
Canals
EARS T.M.'s
Gross Hearing
NOSE Nostrils/Sinuses
Throat
MOUTH Teeth
Gums
Lymph Glands
ENDOCRINE
Thyroid
CARDIOVASCULAR Heart sounds, rhythm, murmur
PULMONARY Lung sounds, chest
Inspection
ABDOMEN Abdominal Masses
Hernia/type
GENITAL (MALES) Genitalia
RECTAL Prostate/Hemorrhoids
MUSCULOSKELETAL Full ROM
LEG VEINS Varicose (Note severity)
BREAST
Coordination
NEUROLOGICAL Motor Function
Needs further evaluation: ____________________________________________________________
Follow up with personal doctor for: ___________________________________________________
____________________________________________________________________________________
Additional Comments: ________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
EXAMINER: ___________________________________________________DATE: ________________
(Please Stamp Form)
PHYSICAL EXAMINATION RECORD Page 1 of 2
PHYSICIAN: Please complete and sign below for validation*
Employee/Applicant NAME (LAST, FIRST, MIDDLE) SAP/EMPLOYEE NUMBER
JOB DUTIES: Comment on any significant positive or pertinent negative medical findings. Include your
opinion as to what, if any, work limitations or workplace modifications are needed to accommodate the examinee. If this
is a pre-placement exam, do NOT comment on whether the examinee should be hired.
□ Medically capable of performing job duties without limitations
□ Requires limitations or restrictions in job duties that are:
□Permanent □Temporary (expected end date) __________________
Explain:
DEPLOYMENT READINESS: Comment on any significant medical conditions that require ongoing
medical care or that could deteriorate while on assignment and require medical services not available in the assignment
location.
Assignment Location: _____________________________________________________________
□ Does not require medical services exceeding the medical capabilities in the assignment location
□ May require medical services not available in the assignment location (explain)
□ Requires on going medical services not available in the assignment location (explain)
Will this individual’s medical status or medical care requirements change in the next 6 months?
NO YES or POSSIBLY (Explain)
EXAMINER __________________________________________________ DATE: ___________________
(Please stamp form)
PHYSICAL EXAMINATION RECORD Page 2 of 2
X
9/28/2023 female 39
OMENYA CAROLINE AKOTH
X
5/23/1984 +254714817408
X
UMOJA NAIROBI KENYA
NAIROBI KENYA
NONE
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X
X
X
X
9|P a g e
NONE
NONE
NONE
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CO
X
CO
CO
CO
X
X 9/21/2023
X
10 | P a g e
Medical Authorization and Release
I acknowledge that the use of and/or possession of prohibited drugs, including
inhalants, and unauthorized alcoholic beverages is a violation of Company
policies.
As a condition of employment and further as a condition of performing services
for my employer in support of existing contracts; I consent to submit to a physical
examination, medical screening, or medical questionnaire(s) as required by my
employer. I also give my consent for specimens to be collected from me to be
submitted for drug and/or alcohol testing and additional medical testing as
required.
I agree that my employment shall be conditional pending the subsequent results
of any medical evaluation and substance testing.
Further, I hereby consent to the release of any and all test results to my employer
for its use or use by an authorized agent.
I release and agree to hold my employer, and all their officers, directors,
employees and agents harmless from any claim or liability which for any reasons
the Company is alleged to be legally liable in conjunction with the physical
evaluation, or the drug and/or alcohol testing.
Date: _____________________________________________
9/23/2023
Employee Name
OMENYA CAROLINE
(Please Print): ______________________________________
Employee Signature: _________________________________
Witness: ___________________________________________
FITNESS EVALUATION CONTINUED - LAB REPORT
To avoid a delay in processing and to ensure confidentiality, fax medical exam/questionnaire and
all test/lab results directly to: KBR HSE fax: (713) 893-6733
BLOOD WORK: Please complete the following blood tests to include Blood Type. All
results must be submitted in English.
CBC (complete blood count)
WBC (white blood cell count)
RSC (red blood cell count)
Hemoglobin
Hematocrit
Platelet count
MCV (mean corpuscular volume)
MCH (mean corpuscular hemoglobin)
ROW (red cell distribution width)
Blood Chemistry:
Glucose PLEASE INCLUDE A COPY OF
Calcium
Phosphorus THE LAB REPORT
Albumin
Total Protein
Globulin
AJG Ratio (albumin to globulin)
Sodium
Potassium
Chloride
C02 (carbon dioxide, bicarbonate)
BUN (blood urea nitrogen)
Creatinine
BUN/Creatinine Ratio
Uric Acid
CPK (creatine phosphokinase)
ALP (alkaline phosphatase)
ALT (alanine transaminase, also called SGPT)
AST (aspartate amino transferase, also called SGOT)
GGT (Gamma-glutamyl transferase)
LOH (lactate dehydrogenase)
Bilirubin
Lipids Profile:
Triglycerides
Total cholesterol
LOL (low density lipoprotein) cholesterol
HDL (high density lipoprotein) cholesterol
Blood Type: (ABO group & RH factor)
Hepatitis Panel
HIV
O&P All food service, quality, ROWPU/Water plant, HSE workers
Pulmonary fit Test (PFT) – All firefighters, HSE, Laborer, Machine Operators (any job title requiring
the use of a respirator)
PSA – All firefighters
Drug Testing Information
Please contact the following KBR Representative to ensure proper drug screen process is
followed.
First Contact person: Jeannette Kaminski
Sr. HSE Specialist
Phone: (713) 753-6805 / Fax: (713) 893-6733
Email: Jeannette.kaminski@us.kbr.com
Jan-ett Little
Sr. HSE Specialist
Phone: (713) 753-2070 / Fax: (713) 893-6733
Email: Jan-ett.Little@us.kbr.com
Donna Smith
HSE Specialist
Phone: (713) 753-7781 / (713) 893-6733
Email: donna.smith@us.kbr.com
• New hires and employees that have been inactive with the company for 90 days or
more are required to submit a specifim (either: urine, blood, saliva, hair) for
laboratory based drug testing.
• Testing must be laboratory based for both screen and, if necessary, confirmation.
Testing with hand written results will not be accepted. Laboratory print out only.
• Results will not be accepted if they are more than 30 days old at the time of
submission.
• When testing in the U.S. the testing must include at minimum a five panel non-
DOT test.
▪ Amphetamine (including Methamphetamine)
▪ Cocaine Metabolites
▪ Marijuana Metabolites
▪ Opiates (including Codeine, Morphine, and Heroin)
▪ Phencyclidine
• All non-negative drug screens must be forwarded to a certified laboratory for
confirmatory analysis (SAMHSA in the U.S.)
• Outside of the U.S. testing will, at minimum, consist of testing for Marijuana and
Cocaine. It is preferred that at least a five (5) panel test be administered wherever
possible.
