Flavoring workers - Medication Form

Appendix K.1: Medication Form (English)

Form Approved

OMB No. 0920-xxxx

Expires xx/xx/20xx

Medication Form

In the table below, please list prescription and non-prescription (over-the-counter) medicine that you take on a regular basis. Please fill out the table below and bring this with you to your appointment.

Name: ______________________________________

Name of medicine	Dose	When taken (such as daily, twice a day, as needed)

Please list any medicine allergies: _____________________________________________________

Public reporting burden of this collection of information is estimated to average 8 minutes or less per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).