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{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Employee_First_Name"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Employee_Last_Name"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Company_Name"
as=${html``}
/>
Physical Exam
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-8a3a372">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Physical_Exam__Pre_Emp_Annual_Exit___please_check_one_"
as=${html``}
/>
Occupational Testing
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-b74d6db">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Occupational_Testing"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-1200b0f">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Audio_Testing"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-497e5b4">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Respiratory_Fit_Test"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-bc14eb6">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Respiratory_Fit_Test"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-d273a12">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Lumbar_X-Ray"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-a57d20a">
<${validation.ErrorMessage}
errors=${validation.errors}
name="X-Ray_Other_"
as=${html``}
/>
Substance Abuse Testing
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-4d89897">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Substance_Abuse_Testing___Please_check_the_reason_for_test_"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-5075726">
<${validation.ErrorMessage}
errors=${validation.errors}
name="If_DOT_Drug__please_specify_agency_"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-80953f3">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Rapid_Instant_Drug_Screen"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-6bdcab7">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Rapid_Instant_Drug_Screen"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-aecbcc8">
<${validation.ErrorMessage}
errors=${validation.errors}
name="In-House_Drug_Screen__Our_Lab___MRO_"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-8ab0c89">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Drug_Screen_COLLECTION_ONLY_-_Specify_TPA_and_Account__"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-9872ad7">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Drug_Screen_COLLECTION_TYPE"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-c30427a">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Alcohol-COLLECTION_ONLY"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Other_Testing"
as=${html``}
/>
Laboratory
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-69f73b8">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Laboratory"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-2fe6208">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Laboratory_II"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-930e4ef">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Immunizations"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-9dfa362">
<${validation.ErrorMessage}
errors=${validation.errors}
name="COVID-19_Testing"
as=${html``}
/>
Due to the Health Insurance Portability Act and Accountability Act (HIPAA) and the Genetic Information Non-Discrimination Act (GINA), we ask that employers refrain from requesting any information pertaining to the employee Genetic History and/or Protected Health Information (PHI).
I understand that by signing this form, I authorize Occucare to treat the above employee and understand that the company listed above will be held responsible for the payment of all fees incurred.
Authorized by:
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Authorized_First_Name"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Authorized_Last_Name"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Title"
as=${html``}
/>
parent.activateValidation({"message":"This field is required.","emailMessage":"Please enter a valid Email address","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Authorizing_Party_Email_Address"
as=${html``}
/>
parent.activateValidation({"message":"This field is required.","emailMessage":"Please enter a valid Email address","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Confirm_Email_Address"
as=${html``}
/>
<${props.SignaturePad}
clearButton="true"
penColor=""
name="mf-signature"
onEnd=${function () { parent.handleSignature(this) }}
/>
parent.activateValidation({"message":"This field is required.","required":false}, el) }
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-signature"
as=${html``}
/>
<${props.Flatpickr}
name="Date"
className="mf-input mf-date-input mf-left-parent "
placeholder="${ parent.decodeEntities(`MM-DD-YEAR`) } "
options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":["01-01-1970"],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}}
value=${parent.getValue('Date')}
onInput=${parent.handleDateTime}
aria-invalid=${validation.errors['Date'] ? 'true' : 'false'}
ref=${el => props.DateWidget(
el,
'',
{"message":"This field is required.","required":true},
register,
parent
)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Date"
as=${html``}
/>
Lonestar Evaluations, DBA Occucare International | DOC.001 Authorization for Occucare Surveillance (OCT2017)