To Obtain from Your Prescribing Health Care Professional
For Ready Submission to A Medical Review Officer (MRO)

To Whom It May Concern:

I have been actively treating _________________________________
(Flight Attendant’s name)
for ________________.
(length of time)
I have prescribed an opioid and/or amphetamine as a part of her/his treatment. I am fully aware of his/her safety sensitive duties as a Flight Attendant. A list of her/his safety sensitive duties is a part of her/his medical record. After a thorough review of these safety sensitive duties, I have concluded that the use of this medication as I have prescribed, does not pose a safety concern.

Doctor’s Printed Name: __________________________________

Doctor’s Signature: _____________________________________

Date: _________________________________________________