Employee Weight Report

EMPLOYEE WEIGHT REPORT

Report Identification

Company Name:    Report ID:

Date of Measurement:    Time:

Personal Information

Phone:    Email:    Date of Birth:

Position & Employment

Reporting Manager:    Employment Start Date:    Employment Status:

Pre-employment    Periodic/Surveillance    Post-illness/injury    Reasonable accommodation review

Safety-sensitive duty evaluation    Wellness program    Other:

Measurement Details

Weight:    Unit:    Height:    BMI (if calculated):

Calibration/Certificate No.:    Measured By (Name & Title):

Weight Trend / Prior Records

Prior Measurement 1 — Date:   Weight:   Measured By:

Prior Measurement 2 — Date:   Weight:   Measured By:

Occupational Health Assessment

Clinical Assessment:

No action required    Follow-up measurement    Refer to Occupational Health    Recommend medical evaluation

Confidentiality & Legal Notices

This weight record constitutes confidential medical and personnel information maintained by the employer for legitimate business and safety purposes. Access to this report is limited to authorized personnel and healthcare professionals. Information will be retained and disclosed only in accordance with applicable privacy and disability laws. The employer will not use this information to unlawfully discriminate against the employee.

Voluntary or required status: The employee acknowledges whether this measurement was required by employer policy or voluntarily provided. Required measurements are a condition of assignment where necessary for safety or accommodation decisions.

Employment History

Dates Employed:    Responsibilities:

Dates Employed:    Responsibilities:

Education

References (Professional)

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Legal Disclosures & Authorizations

At-Will Employment: The employee acknowledges that employment status is at-will unless otherwise set forth in a separate written agreement signed by an authorized representative of the employer. Nothing in this report or in any discussion associated with it alters the at-will relationship.

Equal Employment Opportunity: The employer provides equal employment opportunity and will not discriminate on the basis of disability, medical condition, or any other legally protected characteristic. Any employment decision arising from this report will comply with applicable non-discrimination and accommodation obligations.

Applicant Certification: I certify that all information provided in this Employee Weight Report and accompanying entries is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation may subject me to disciplinary action, up to and including termination.

Authorization to Contact and Background Checks: I authorize the employer and its authorized agents to contact prior employers and professional references listed herein to verify employment history and related information. I further authorize the employer to obtain background checks where permitted by law, and to use the information obtained for employment and occupational health decisions. I understand that certain employment decisions may depend on the results of such verifications and checks.

Privacy and Use Limitation: I understand the results of this report will be used only for legitimate business, safety, medical, and accommodation purposes and will be handled as confidential medical information consistent with applicable law.

Acknowledgement & Consent

By signing below, I acknowledge receipt of this Employee Weight Report, confirm the accuracy of the entries I have provided, and consent to the collection and use of the measurement data as described above. I further consent to contact with prior employers and to background checks as authorized above.

I understand I may request access to the information contained in my personnel and medical file as provided by applicable law and company policy.

Sign Now