Employment Medical Fitness Non-Employed Form

EMPLOYMENT MEDICAL FITNESS NON-EMPLOYED FORM

Purpose: This form documents medical history, immunization status, and clinical evaluation for individuals not currently employed by the organization who are required to undergo a medical fitness assessment prior to assignment, volunteer work, training, or other activities. Completion of this form and any required clinical testing is a condition of consideration for placement. Health information provided will be treated as confidential medical records and released only as necessary for retention or accommodation decisions.

Personal Information

Position / Assignment Information

Anticipated Start Date:

Full-time    Part-time    Temporary    Volunteer

Emergency Contact

Medical History

Please check any of the following conditions that you currently have or have had in the past. Checking a box does not automatically disqualify you; additional information or testing may be required.

Asthma / Reactive Airway Disease    Diabetes    Hypertension    Heart disease / Arrhythmia

Seizures / Neurologic disorder    Back or spinal problems    Psychiatric disorder    Bleeding disorder / Anemia

Immunization and Testing Status

Provide dates where known. If documentation is attached, indicate so below.

Functional Abilities / Work Requirements

The clinical determination will consider the essential functions of the assignment. Please indicate whether you can perform the essential job functions with or without accommodation.

I can perform essential duties: Yes    If no or with restrictions, provide details below.

Consent, Authorization and Certifications

Authorization for Examination and Release: I authorize a licensed medical professional to perform a medical examination and any tests reasonably related to the evaluation of my fitness for the requested assignment. I authorize release of the examination results, including records of immunizations, test results, and any recommended restrictions, to the organization for purposes of placement, reasonable accommodation, and health and safety determinations. I understand that medical information will be kept confidential and will be used only as permitted by law and organizational policy.

Background / Employment Verification Authorization: I authorize the organization to contact previous employers and professional references to verify employment history and fitness for duty as necessary to assess placement. I further consent to any required pre-assignment drug or alcohol screening and understand that refusal to submit to testing may preclude placement.

Authorization to Collect Specimens: I consent to the collection of blood, urine, or other biological specimens if required for vaccination titers, infectious disease testing, or drug screening related to this evaluation.

By checking this box I consent to the examination, testing, and release as described above.

Applicant Certification

I certify that all information provided on this form is true, accurate, and complete to the best of my knowledge. I understand that knowingly providing false or misleading information may result in denial of placement or removal from assignment. I authorize release of medical information as set forth above and acknowledge that the final determination of medical fitness rests with the organization based on clinical findings and applicable policies.

I certify that the statements above are true and complete.

Employment History (At least two employers)

Education

Professional References (Three)

Medical Provider Evaluation (To be completed by clinician)

Clinical findings and recommendations should be based on history, examination, and any indicated testing. This section documents the clinician's assessment of fitness for the requested assignment.

Fitness Determination: Fit for assignment without restrictions Fit with restrictions Temporarily unfit / Not fit

Equal Opportunity and At-Will Statements

Equal Opportunity: The organization provides equal opportunity for assignment and placement without discrimination on the basis of protected characteristics in accordance with applicable law. Medical fitness determinations are made on the basis of clinical findings, essential job functions, and applicable law regarding disability and reasonable accommodation.

At-Will: Submission of this form does not create an employment contract. Placement decisions are administrative determinations and, if placement occurs, may be governed by at-will policies unless otherwise specified in a written agreement.

Authorization to Contact Previous Employers and Conduct Background Checks

I authorize the organization to contact prior employers and listed references to verify information provided and to evaluate my suitability. I consent to background screening, which may include criminal history checks and verification of credentials where permitted by law.

I authorize verification of employment history, references, and background checks as described.

Release and Authorization Signature

By signing below, I acknowledge that I have read and understand the statements and authorizations contained in this form, and I authorize the release of medical information necessary for the organization to make placement decisions or to provide reasonable accommodations.

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