Employee Exam Release Form

EMPLOYEE EXAM RELEASE FORM

Personal Information

Employee Name:

Position Information

Reporting Manager:     Anticipated Start Date:

Exam Details and Authorization

Type(s) of exam authorized (check all that apply):

Medical Examination    Psychological Evaluation    Drug/Alcohol Screening    Fitness-for-Duty Assessment    Other (specify below)

Exam Provider/Facility Name:

Scheduled Exam Date:     Scheduled Exam Time:

Authorization to Release and Obtain Information

I, the undersigned employee, hereby authorize any licensed physician, medical practitioner, laboratory, clinic, hospital or other medical facility that performs the authorized exam(s) to disclose to my employer and its designated representatives any medical information, records, laboratory results, diagnostic reports, and fitness-for-duty conclusions that relate to the purpose stated in this form. This release includes but is not limited to physical examinations, mental health evaluations, drug and alcohol testing results, vaccination records, and diagnostic testing.

I further authorize my employer to obtain, review and retain copies of such records for employment-related determinations, including fitness for duty, reasonable accommodation analysis, job assignment, and public safety determinations. I understand that health information released pursuant to this authorization may be used by my employer for employment-related determinations and may be placed in my personnel file or a separate medical file maintained by the employer.

This authorization is valid for the period beginning on the date signed below and shall remain in effect for 12 months unless revoked in writing earlier. I understand that I may revoke this authorization at any time by providing a written revocation to the employer, but such revocation will not affect disclosures already made in reliance on this authorization prior to the employer's receipt of the revocation.

Release and Waiver of Claims

In consideration of the employer arranging and permitting the authorized examinations, I release, discharge and hold harmless the employer, its officers, agents, employees, and the exam provider from any and all claims, liabilities, or causes of action that may arise from the administration of the exams, the release or use of exam results as authorized herein, or any employment actions taken in good faith reliance on such results, except where prohibited by law.

I understand that refusing to submit to a required exam, or falsifying information related to the exam, may result in disciplinary action up to and including separation of employment when such refusal prevents the employer from making a required safety, fitness, or compliance determination.

Employment History

Employer 1

Dates Employed: From to

Employer 2

Dates Employed: From to

Education

Graduation Date:     Major/Concentration:

Professional References

Reference 1

Reference 2

Reference 3

Legal Disclosures

At-Will Employment: I acknowledge that my employment, if any, is at-will unless a written agreement signed by an authorized representative of the employer states otherwise. Nothing in this release changes the at-will nature of employment.

Equal Opportunity: The employer is an equal opportunity employer. Employment decisions are made on a non-discriminatory basis in accordance with applicable law.

Authorization for Background and Reference Checks

I authorize the employer to contact previous employers and references provided on this form to verify information, to obtain information regarding my job performance and suitability for employment, and to conduct any background checks required by the employer as permitted by law. I understand that the results of such checks may be used to make employment decisions.

I understand I have rights with respect to medical information and testing under applicable law. To the extent required, I acknowledge that I have received any required notices and that my written authorization is being provided voluntarily for employment-related purposes.

By signing below I certify that all information contained in this form is true and complete to the best of my knowledge. I further certify that I have read and understand the authorizations, releases, and waivers contained in this document and consent to the actions described. I acknowledge that falsification, omission, or misrepresentation of information may be grounds for refusal to hire or for termination of employment.

I authorize the release and disclosure of medical information as described above and waive any claim against the employer and exam provider arising from the release and use of such information in accordance with this authorization.

I consent to the background and reference checks described and authorize the release of my prior employment records for this purpose.

Employee Signature Indicates Acceptance of All Terms Above.

Sign Now