Referral for a Pre-Employment or Periodic Medical Examination

Employer / organization​ No. Document number​ dated Document date

Employer: Employer / organization​. Email: Employer's email​; telephone: Employer's telephone​. Employer's primary state registration number for a legal entity / individual entrepreneur (ОГРН/ОГРНИП): Employer's primary state registration number (ОГРН/ОГРНИП)​. Form of ownership: Employer's form of ownership​. Economic activity and Russian classification code (ОКВЭД): Economic activity and classification code (ОКВЭД)​. Medical organization: Medical organization's name​. Actual address: Medical organization's actual address​. Primary state registration number (ОГРН): Medical organization's primary state registration number (ОГРН)​. Email: Medical organization's email​; telephone: Medical organization's telephone​. Examination type: pre-employment.

Full name: Referred person's full name​. Date of birth: Date of birth. Sex: Sex as recorded in documents​. Status: person entering employment. Position / occupation / type of work: Position / occupation / type of work​. Mandatory and/or voluntary medical insurance policy number (ОМС/ДМС): Mandatory and/or voluntary medical insurance policy number (ОМС/ДМС)​.

The referral is based on the approved list: Particulars of the approved list of persons / named employee list​. Harmful and/or hazardous workplace factors and types of work: Harmful / hazardous factors and types of work​ Specific work performed and items of the applicable schedule: Specific work types and schedule items​. The examination follows Order of the Ministry of Health of Russia of 28.01.2021 No. 29n (29н). The employer arranges recording of referrals issued. Registration entry: Referral issue registration entry​. Employer's authorized representative: Signatory's position​ ______________ / Head's full name​ /. Basis of authority: Basis of the representative's authority​. Referral received on Date referral received: ______________ / Referred person's full name​ /.