Employee Health Form

EMPLOYEE HEALTH FORM

Personal Information

Employee Name:

Phone:    Email:

Date of Birth:    Employee I.D.:

Position Information

Job Title:    Department:

Reporting Manager:    Start Date:

Emergency Contact

Relationship:    Phone:

Health Insurance & Provider

Insurance Provider:    Policy / ID #:

Phone:    Address:

Medical History — Check all that apply

  Heart disease / heart attack      Hypertension      Diabetes

  Asthma / COPD      Seizure disorder      Cancer

  Psychiatric condition      Severe allergies (see details)      None of the above

Immunizations & Testing

Influenza vaccine this season: Yes    Date:

Tetanus within 10 years: Yes    Date:

Other immunizations / occupational tests (list and date):

Fitness for Duty & Accommodation

I am able to perform the essential functions of my position with or without reasonable accommodation:   Yes

I request reasonable accommodation for health-related limitations:   If yes, describe below

Authorization & Release

By signing below, I certify that the information contained in this Employee Health Form is true and complete to the best of my knowledge. I understand that material misstatements or omissions may be grounds for disciplinary action up to and including termination.

I authorize the employer and its designated medical reviewers to contact my physician or other healthcare providers for the purpose of verifying health information relevant to my fitness for duty and accommodation requests. I further authorize the release of relevant medical information to the employer on a need-to-know basis for job-related decisions. I understand that except as required by law, my medical information will be kept confidential and maintained separately from my personnel file.

I also authorize the employer to collect and use information from prior employers or third-party background and medical records as necessary to evaluate my ability to perform job duties safely and in compliance with job-specific medical requirements. I acknowledge that submission of this form is a condition of employment when required by the employer for safety-sensitive positions.

Employment History

Employer 1

Title:    Dates:

Employer 2

Title:    Dates:

Education

Graduation Date:

References

Reference 1

Phone:    Email:

Reference 2

Phone:    Email:

Reference 3

Phone:    Email:

Legal Disclosures & Certifications

At-Will Employment: Nothing in this form alters the at-will employment relationship between the employee and the employer unless expressly provided in a separate written agreement signed by an authorized representative of the employer.

Equal Opportunity: The employer provides equal employment opportunity and will not unlawfully discriminate on the basis of race, color, religion, sex, national origin, age, disability, or other protected classifications under applicable law.

Applicant Certification: I certify that all information provided on this form is true and complete. I understand that the employer may verify the information provided and that falsification or omission of material facts may be cause for disciplinary action, including termination.

Authorization for Background and Medical Inquiries: I consent to the release of employment-related records and medical information as necessary for the employer to evaluate my fitness for duty, safety risk, and need for reasonable accommodation. I understand that such records will be used in accordance with applicable privacy and employment laws.

Sign Now