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RF-F09 – Prescribed Medical Usage
RF-F09 - Prescribed Medical Usage
Employees Name
First
Last
Job Title
Date
MM slash DD slash YYYY
Manager notified
*
Yes
No
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.
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