Benzene Packet

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The deadline for online questionnaire submissions for employees being tested at our mobile units is a week prior to the start of the job. Be aware that we cannot access any forms after the deadline on the mobile units and paper copies will need to be completed.
Alliance Health Resources Mobile Division Ltd. | 2910 Center St
Deer Park, TX | 77536 | 281.479.6672

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Benzene Packet consists of the Benzene, Medical History, OSHA and Hearing questionnaires.

Step 1 of 8

Name
This field is for validation purposes and should be left unchanged.
Release of Medical Information
Name*
First Last
Date of Birth*
Month
Day
Year
SS#*
Gender
- Male
- Female
- Prefer not to answer
Race*
Employee ID*
Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code
Cell Phone*
Text Message Consent*
- I consent to receive updates via text message.
- I do not consent to receive updates via text message.
Personal Email*

Your Results may be sent to you by email. Please provide an email for which you can receive your results. Most company firewalls will block outside e-mails, please provide a personal email address.
I hereby authorize ALLIANCE HEALTH RESOURCES Mobile Division, Ltd. to release all information obtained during medical surveillance and occupational related encounters to:
Company*
Company Contact Name*
Company Contact Address*
Street Address City State / Province / Region ZIP / Postal Code
- This authorization shall expire one year after my employment with the company above ceases.
- I may revoke this authorization in writing by contacting your office at the above address.
- I understand that I may periodically be asked to update this Medical Release Form at the discretion of Alliance Health Resources Mobile Division, Ltd.
- I understand that my authorization provided above means that the authorized organization can disclose,communicate or send my protected health information to the organization, entity or person identified above, including through the use of electronic means.
Signature*
Date*
MM slash DD slash YYYY

Benzene Packet

Helpful Links

Benzene Packet

Step 1 of 8

Release of Medical Information

Benzene Questionnaire

Medication List

Medical and Occupational Health History

Current Employment

Most Recent Previous Employment

Previous Position

OSHA Respirator Medical Evaluation

OSHA Respirator Medical Evaluation

Hearing History