Brady Act Pre-Employment Physical Medical Examination Form



SAMPLE FORM – USE AS A TEMPLATE FOR YOUR CITYPhysical Medical Examination Cancer Screening/WaiverYou are employed as a Firefighter with the City of ____________________________. A Cancer Presumption Bill has been established for firefighters pending passing a physical medical examination cancer screening. Please read the information below.Tennessee’s Barry Brady Act (Act) establishes a rebuttable presumption that if a firefighter contracts one of the four cancers listed below, that the cancer arose out of employment, unless the contrary is shown by competent medical evidence.The four cancers covered by the Act are:all forms of Non-Hodgkin's Lymphoma cancer;colon cancer;skin cancer; ormultiple myeloma cancer.The presumption is not automatic, and the Act states that a firefighter who desires to use the presumption must successfully pass a pre-employment physical medical examination, and the examination must include a cancer screening that fails to reveal any evidence of the cancers listed in the Act. The decision to have the cancer screening rests with you, the employee. Please indicate your desire by checking only one of the two boxes below and signing the form.left6985Yes, I desire to have the cancer screening included as part of my Annual Physical Medical Examination.left5080No, I decline to have the cancer screening included as part of my Annual Physical Medical Examination.________________________________________________________Signature of ApplicantDate____________________________________Witness ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download