Occupational Medicine | Document Downloads

Occupational Medicine

Document Downloads

Request for Services Authorization Form

Although not required for an appointment, a Request for Services Authorization form is strongly recommended. This form confirms the services requested and protects the company from unnecessary charges.

  Request for Services - Authorization

Designated Medical Provider Selection Form

In order to select Trinity Health as a Designated Medical Provider, this form needs to be filled out and sent to North Dakota Workforce Safety and Insurance at the address listed on the form. A copy of the form can be sent to:
Trinity Health Occupational Medicine
Attn: Jordan Schmitt
PO Box 5020
Minot, ND 58702

  Designated Medical Provider Selection Form

Respirator Questionnaire

An employee whose job duties may require the use of a mask or respirator must be medically evaluated using the OSHA Respirator Questionnaire. The questionnaire identifies breathing or cardiac conditions that may place the employee at risk.

  Respirator Questionnaire

NDWSI Ergonomic Initiative Program

Trinity Health is a vendor for the North Dakota Workforce Safety and Insurance Ergonomic Initiative Program.

  Download our informational handout
  Download an application form to the program

DOT Examination Forms

If possible, please have the Driver Information section of the Medical Examination Report Form complete prior to your appointment. Use the Federal DOT Exam Requirements Checklist to determine what items you need to bring to your appointment, applicable to your personal health history.

  Download DOT Medical Examiners Report
  Download Federal DOT Exam Requirements Checklist

 Providers in this field:
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