RF-F09 – Prescribed Medical Usage

RF-F09 - Prescribed Medical Usage

Employees Name
First Last
Job Title
Date
MM slash DD slash YYYY
Manager notified*
Safety Critical Post
- Yes
- No
Medication obtained via:
- Prescribed
- Over the Counter
- Medical Practitioner
- Pharmacist
Date commenced medication
MM slash DD slash YYYY

Medication Information

Details of Medication Taken	Dosage	Frequency	Period of Use

Details any known side effects:
Action taken:
- Can work as normal
- Can work, but must be accompanied
- Remove from duties (see prescribing GP for review of medication if possible)
- Remove from duties
Completed form should be returned to the Rail Administrator
Phone
This field is for validation purposes and should be left unchanged.