Employee Health & Safety Questionnaire

EMPLOYEE HEALTH & SAFETY QUESTIONNAIRE

Personal Information

Employee Name:

Position & Employment Details

Reporting Manager:

Proposed Start Date:

Emergency Contact

Health & Safety Assessment

1. In the past 12 months, have you sustained a work-related injury or illness requiring medical treatment? Yes No

2. Do you currently have any medical condition, physical limitation, or impairment that may affect your ability to perform job duties or to operate equipment safely? Yes No

3. Are you currently taking medication that could affect alertness, balance, coordination, or the safe operation of machinery or vehicles? Yes No

4. Do you have any diagnosed hearing or vision impairments that are uncorrected or require assistive devices while performing job duties? Yes No

5. Are you allergic to any substances, chemicals, or materials that may be present in the workplace (e.g., latex, solvents, bee stings)? Yes No

6. Can you wear required personal protective equipment (PPE) including respirators, safety glasses, hearing protection, or safety footwear without limitation? Yes No

Work History (Most Recent Employers)

Dates Employed: From To

Dates Employed: From To

Education

Graduation Date:

References

Legal Disclosures & Authorizations

At-Will Employment: Nothing in this questionnaire modifies the at-will nature of employment. Employment may be terminated at any time by the employee or the employer, with or without cause or advance notice, subject only to applicable law and any written agreement signed by an authorized company representative.

Equal Opportunity: The company provides equal employment opportunity without regard to race, color, religion, sex, national origin, age, disability, genetic information, or any other protected characteristic. Reasonable accommodations for known disabilities will be considered in accordance with applicable law.

Medical Information and Confidentiality: Medical information provided on this form will be treated as confidential health information and maintained separately from personnel records. Such information will be used only to evaluate fitness for duty, to implement reasonable accommodations, to protect employee safety, and to meet legal obligations.

I authorize the company and its agents to contact my past employers, professional references, and medical providers as necessary to verify information relevant to my ability to safely perform the essential functions of the position. I further authorize release of job-related medical information to the company for the purpose of evaluating reasonable accommodations and safety-related work restrictions.

I consent to a background check and any job-related health or fitness-for-duty evaluations that the company deems necessary, provided such evaluations are job-related and consistent with business necessity.

Consent to contact previous employers and conduct background/health inquiries: Yes No

Applicant Certification

I certify that the information provided on this Employee Health & Safety Questionnaire is true, accurate, and complete to the best of my knowledge. I understand that knowingly providing false or misleading information may result in disciplinary action, up to and including termination of employment. I agree to promptly notify the company of any change in my medical status that may affect my ability to perform my job duties safely.

Sign Now