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Occupational Health
Health and Wellness
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Request Appointment
Contact Us
Administrative Offices:
622 Osborne Road
Fridley, Minnesota 55432
This form should be used for scheduling Occupational Health appointments only.
After submitting the form, please allow at least 24 hours for our Scheduling Department to contact you and confirm your appointment request.
Company:
(required)
Reply To:
(required)
Phone:
(required)
First Name:
(required)
Last Name:
(required)
Physical Exam Postion:
(required)
none
Preplacement Basic Exam Only
Preplacement DOT Exam - Current Employee
Preplacement DOT Exam - DOT Certification only (not preplace)
Preplacement DOT Exam - New
Respirator Clearance - Baseline
Respirator Clearance - Exit
Respirator Clearance - Periodic
Surveillance (HazMat) - Baseline
Surveillance (HazMat) - Exit
Surveillance (HazMat) - Periodic
(required)
Preferred week day for appointment:
No Preference
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred time for appointment:
Drug Screening:
none
DOT, a.k.a. NIDA, or Federally regulated
Non-DOT, a.k.a. or Non-NIDA, Private Sector
none
both (Breath alcohol & Urine drug collection)
Breath alcohol
Urine drug collection
Reason for Testing:
Return to Duty
Reasonable Suspicion
Random
Post Accident
Job Applicant
Follow Up Testing
other
Appointment Location:
No Preference
Fridley
Blaine
Roseville
Enter any general comments/questions in the space below: