Template

Refusal for Medical Treatment and Observation Form

by Joshua Kelsey, from the Community

10+

Use this form to record an employee decision to refuse medical treatment or observation after a workplace incident. Capture the incident date, preparer, employer details, confirmation that treatment or observation was offered in good faith, understanding of potential costs and lost wages, and the employee signature. Suitable for workplace health and safety documentation and incident follow up. Review and adapt to meet your requirements.

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Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
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Use this medical waiver form to document when an employee chooses not to seek immediate medical treatment after a workplace incident. Capture key details including site information, site number, supervisor or foreman, employee name and position, and the date and time of the incident. Obtain employee and foreman signatures and dates. The form reinforces notifying the foreman and safety department before seeking treatment later, supporting incident documentation and injury management processes.
by Peter Affum, from the Community
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Authorization for Medical Treatment and Release of Records
An employer-focused consent form that authorizes approved providers to deliver medically necessary treatment after an occupational injury and to release medical records to the employer. Includes fields for employee details, incident description, manager authorization, pharmacy information, and instructions for required drug and alcohol screening. Suitable for workplace health, safety, and workers' compensation documentation.
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Refusal to File Workers Compensation Benefits
This template documents an employee decision to refuse filing workers compensation benefits and decline medical treatment following a reported workplace injury. It provides structured fields for employee and supervisor names, job name or number, location, document number, and the date and time of signature. The statement section records acknowledgement that a claim form and medical care were offered and declined, and that the signature is voluntary. Use this form to capture essential details, maintain compliance records, and ensure clear acknowledgment with printed names and signatures.
by Kirk Williamson, from the Community
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First Aid Treatment Form
A comprehensive digital first aid treatment form designed for university first aiders and medical professionals. This template enables systematic documentation of casualty details, incident information, and medical treatments administered. The form includes sections for patient personal information, incident details, treatment records, medical referrals, and necessary signatures. It features options for referring patients to various medical facilities including A&E, GP, and University Medical Centre. The digital format allows for easy submission and record-keeping through email integration, making it an essential tool for maintaining accurate medical incident records in educational institutions.
by Paul Turnbull, from the Community
Downloads: 50+
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Agrodrain Medical Waiver Form

Use this medical waiver form to document when an employee chooses not to seek immediate medical treatment after a workplace incident. Capture key details including site information, site number, supervisor or foreman, employee name and position, and the date and time of the incident. Obtain employee and foreman signatures and dates. The form reinforces notifying the foreman and safety department before seeking treatment later, supporting incident documentation and injury management processes.

by Peter Affum, from the Community

20+

Get

Template

Authorization for Medical Treatment and Release of Records

An employer-focused consent form that authorizes approved providers to deliver medically necessary treatment after an occupational injury and to release medical records to the employer. Includes fields for employee details, incident description, manager authorization, pharmacy information, and instructions for required drug and alcohol screening. Suitable for workplace health, safety, and workers' compensation documentation.

by Josh McComas, from the Community

10+

Get

Template

Refusal to File Workers Compensation Benefits

This template documents an employee decision to refuse filing workers compensation benefits and decline medical treatment following a reported workplace injury. It provides structured fields for employee and supervisor names, job name or number, location, document number, and the date and time of signature. The statement section records acknowledgement that a claim form and medical care were offered and declined, and that the signature is voluntary. Use this form to capture essential details, maintain compliance records, and ensure clear acknowledgment with printed names and signatures.

by Kirk Williamson, from the Community

20+

Get

Template

First Aid Treatment Form

A comprehensive digital first aid treatment form designed for university first aiders and medical professionals. This template enables systematic documentation of casualty details, incident information, and medical treatments administered. The form includes sections for patient personal information, incident details, treatment records, medical referrals, and necessary signatures. It features options for referring patients to various medical facilities including A&E, GP, and University Medical Centre. The digital format allows for easy submission and record-keeping through email integration, making it an essential tool for maintaining accurate medical incident records in educational institutions.

by Paul Turnbull, from the Community

50+

Get

Refusal for Medical Treatment and Observation Form

About author

You might also like

Agrodrain Medical Waiver Form

Authorization for Medical Treatment and Release of Records

Refusal to File Workers Compensation Benefits

First Aid Treatment Form

You might also like

Agrodrain Medical Waiver Form

Authorization for Medical Treatment and Release of Records

Refusal to File Workers Compensation Benefits

First Aid Treatment Form