Can this form be signed electronically?

Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and generally under UETA in most states; ensure the signer demonstrates intent, consents to electronic records, and that record reproduction is possible.

Is medical information in the form protected by HIPAA?

Only when the employer is a HIPAA-covered entity or the data qualifies as protected health information handled by a covered entity. In many employment contexts ADA confidentiality and state privacy laws apply; treat data as sensitive and restrict access.

What if a candidate refuses to complete the questionnaire?

Refusal may prevent finalizing a conditional offer when the questionnaire is a lawful condition of employment; however, employers must avoid discriminatory follow-up and consider whether accommodations or alternative evaluations apply under the ADA.

Who should have access to completed forms?

Limit access to HR and occupational health personnel on a need-to-know basis. Store medical information separately from general personnel files to maintain confidentiality and compliance.

How do I secure electronic submissions?

Use platforms offering TLS in transit, AES-256 at rest, audit logging, and a HIPAA BAA when PHI is involved. Configure signer authentication and conditional field visibility to reduce exposure.

How long must completed forms be kept?

Retain records consistent with federal standards and industry rules: at least 3 years for employment-related records, and 6 years when HIPAA applies (45 CFR §164.530(j)); check state statutes for longer retention requirements.

Electronic Signature
Templates
HR
Employment Post Job Offer Medical History Questionnaire

Employment Post Job Offer Medical History Questionnaire

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Employment Post Job Offer Medical History Questionnaire

PBSD 1218 (Rev. 5/28/2015) RECORD COPY - Risk and Benefits Management

First Name

M.I.

Last Name

1. Have you ever had or been treated for any of the following conditions or diseases?

Epilepsy Mental retardation Kidney or bladder trouble Diabetes Meniscectomy Ulcers Cardiac disease (heart trouble) Patellectomy Headaches or head injury Arm injury Ruptured Cruciate Ligament Cancer Total loss of sight of one or both eyes or partial loss of corrected vision of more than 75% bilaterally Surgical or Spontaneous Fusion of a major weight bearing joint Dizziness or fainting spells Residual disability from Polio One or more back injuries or disease process of the back resulting in disability over 120 or more days Arthritis or Rheumatism Cerebral Palsy Prior work related accidents Spinal/Disc trouble/injury Multiple Sclerosis Any permanent physical condition constituting impairment of a member or body as a whole Obesity (30% above average for height and age) Parkinson's Disease Rheumatic Fever Shoulder injury Hemophilia High Blood Pressure Alcoholism addiction or treatment Chronic Osteomyelitis (bone infraction) Varicose veins or leg ulcer Drug addiction or treatment Hyperinsulinism (low blood sugar) Chest pain Severe headaches Muscular Dystrophy Tuberculosis Chronic cough Thrombophlebitis Allergies (chemical or other) Shortness of breath Back trouble/injury Hay Fever or Asthma Nervous breakdown Elbow trouble/injury Skin trouble Ever been injured on the job? Total deafness Reaction to serum or drug Neck trouble/injury Foot trouble/injury Hip trouble/injury Operation/Surgery Hand trouble/injury Joint trouble/injury Serious illness Heat Stroke Knee trouble/injury Serious injury Hernia Leg trouble/injury Shoulder trouble/injury Tobacco use Wrist trouble/injury Ever changed employment for your health Is there any type of work you cannot do for health reasons Lost time from work due to serious illness or injury Ever filed a workers’ compensation claim? Advised to have or contemplate having surgery Refused employment or life insurance because of your health Mental illness, psychiatric treatment or professional counseling Any other illness, injury, treatment not listed on this form? Ever had an impairment rating? Ever denied a workers' compensation claim?

2. Please list any condition or diseases for which you have been treated in the past 3 years. If no treatment has been provided, state "none."

3. Have you ever been hospitalized? If so, for what condition? If you have not been hospitalized, state "none."

4. Have you ever been treated by a psychiatrist or psychologist? If so, for what condition? If no such treatment has been received, state "none."

5. Have you ever been treated for any mental condition? If so, please explain. If no such treatment has been received, state "none."

6. Is there any health-related reason, you may not be able to perform the job for which you are applying? If yes, please explain.

7. Have you had a major illness in the last 5 years? If none, state "none."

8. How many days were you absent from work because of illness last year? If none, state "none."

9. Do you have any physical conditions which preclude you from performing certain kinds of work? If yes, describe such conditions and specific work limitations. If none, state "none."

10. Do you have any disabilities or impairments which may affect your performance in the position for which you are being considered?

11. If you listed disabilities or impairments in #10 above, what accommodation(s) do you suggest?

12. Are you taking any prescription drugs? If yes, state the medication and the reason for taking it. If no medications are being taken, state "none."

13. Have you ever been treated for drug addiction or alcoholism? If yes, identify the medical care provider and dates of treatment. If no treatment has been provided, state "none."

14. Have you ever filed for workers' compensation insurance? If yes, please explain and include permanent impairment rating assigned, if any.

NOTE: ALL QUESTIONS ANSWERED "YES" MUST BE FULLY EXPLAINED. Include date, diagnosis, treatment, result and doctor/hospital in the area below.

SPACE TO ANSWER QUESTIONS ANSWERED "YES": (Give the number you are explaining) Continue on reverse if needed.

If I have an on-the-job injury, or if The School District of Palm Beach County (hereinafter PBCSD) needs to obtain medical details identified by me on the first, second and third pages of this questionnaire, I authorize any physician, medical practitioner, hospital, clinic or other health facility, or employer, to release any and all medical information in its possession about me to PBCSD, or its legal representatives, as long as I am employed by PBCSD. Medical information means all information in the possession of or derived from providers of health care regarding the medical history, mental or physical condition, or treatment of me. I understand that I may request a copy of this authorization form. I affirm that all the facts and information given on this form are true and complete. I understand that any false, incomplete or misleading information given by me on this form, regardless of when it is discovered, is sufficient cause for rejection of my application or termination of my employment with PBCSD. I understand and agree that any change in my medical history, as reported on this form, affecting my ability to perform any part of my assignment will be reported in writing to PBCSD immediately upon occurrence of such change.

Your Signature

Date

Witness

Medical History Questionnaire

I hereby affirm that the School District of Palm Beach County (PBCSD) has made me an offer of employment, conditioned on the satisfactory completion of this questionnaire and, if necessary, within the sole discretion of the School District, a medical examination. The purpose of this inquiry is to determine whether I currently have the physical or mental qualifications necessary to perform the job that has been offered, whether and what accommodations may be necessary, and whether I can perform the job without posing a direct threat to the health or safety of myself or others and for the purpose and reasons as stated on the attached questionnaire.

This information will be kept confidential in a separate medical file, apart from my personnel file. I hereby affirm that the questions as found in the attached medical questionnaire have not been asked of me by anyone with the School District of Palm Beach County until after I have signed this statement and been offered a job.

I declare that the answers given by me to the foregoing questions and statements are true and correct without pertinent omissions. I agree that the Board shall not be held liable if my employment is terminated because of the falsity of statements, answers or omissions made by me in this application. I also authorize all former employers, schools, and the persons named above to give any information regarding my employment, together with any information they may have regarding me. I hereby release said employees, schools, or persons from all liability for issuing this information.

Name

Social Security Number

Signature

Witness

Witness Date

What this post-offer medical history questionnaire is and when employers use it

The Employment Post Job Offer Medical History Questionnaire collects medical and health-related information from a candidate after a conditional job offer. Employers use it to assess fitness for specific job duties, identify reasonable accommodation needs under the ADA, and document medical clearances where permissible. The form should avoid pre-offer medical inquiries, be narrowly tailored to job-related requirements, and include consent and data-protection language when health information is collected or transmitted electronically.

Why a structured post-offer medical history questionnaire matters

A well-designed questionnaire protects employers and applicants by documenting job-related health screening, supporting ADA accommodation decisions, and reducing legal risk. When completed after a conditional offer it aligns with ADA requirements and can be managed electronically under ESIGN (15 U.S.C. ch. 96) and state e-signature law where applicable.

Who handles and completes the questionnaire

Typical users include HR, occupational health staff, hiring managers, and the candidate completing the form.

HR teams: Manage distribution, consent tracking, and retention consistent with employment policies.
Occupational health: Review medical details, recommend reasonable accommodations, and clear fitness-for-duty issues.
Candidates: Provide truthful responses, sign required authorization, and update information as needed.

Each party has distinct responsibilities: the candidate supplies accurate information, clinical reviewers assess fitness, and HR documents decisions and accommodations.

Step-by-step: completing the questionnaire from receipt to review

Follow these sequential steps to submit accurate information and ensure compliant review.

01

Review instructions: Read consent and privacy language before entering any health information.
02

Provide responses: Complete required fields clearly and use MM/DD/YYYY where dates are requested.
03

Sign authorization: Electronically sign the release or consent block to permit medical verification if needed.
04

Employer review: Occupational health or HR assesses responses and documents accommodation or clearance decisions.

How to configure an online workflow for this form

Set up fields and routing to enforce required steps, capture audit data, and preserve confidentiality when health data is involved.

Field	Configuration
Authentication	Email link or SMS code; consider stronger ID verification for sensitive medical data
Conditional fields	Show follow-up questions only when prior answers indicate relevance
HIPAA BAA	Enable if the employer is a covered entity or if PHI will be stored/processed
Audit & retention	Capture timestamps, IP, and signer identity; configure storage duration per policy

Typical document routing and submission path

This simplified flow shows the common routing when using an e-signature-enabled form for post-offer medical history.

Upload form: Employer uploads questionnaire template and places fields.
Assign signer: Send to candidate using secure email or signing link.
Authentication: Candidate verifies identity and completes answers.
Review & store: HR or medical reviewer records outcome and archives securely.

Digital delivery options and technical requirements

Choose a platform that supports secure file formats, authentication, and compliance controls for health data.

Integrations: Connect with HRIS, ATS, and cloud storage like Google Workspace or NetSuite
File formats: PDF, DOCX support with fillable fields preserved
Security: TLS in transit, AES-256 at rest; HIPAA support when required

Essential elements to include in a professional questionnaire

Design the form to collect only job-related medical information, document consent, and preserve an audit trail for each submission.

Job-Related Questions

Limit questions to medical issues that directly affect essential job functions and safety; avoid broad, invasive queries.

Consent Language

Clear, plain-language authorization for collecting and sharing medical information consistent with privacy law requirements.

Accommodation Request

A dedicated section for candidates to describe accommodations they need and severity or frequency constraints.

Verification Clause

Optional provider verification section with explicit release that meets applicable disclosure rules.

Signature Block

Date-stamped signature field that meets ESIGN/UETA standards for attribution and intent to sign.

Audit Record

Automatic capture of signer IP, timestamp, and action log for compliance documentation.

Security and compliance controls to protect medical information

Encryption in transit: TLS 1.2/1.3

Encryption at rest: AES-256

HIPAA compliance: BAA required for covered entities

Audit trails: Timestamped action logs

Authentication: Email/SMS; optional advanced signer verification

Certifications: SOC 2 Type II, ISO 27001

Key legal and operational risks of handling medical questionnaires improperly

ADA violation: Unlawful pre-offer medical inquiries can prompt discrimination claims

HIPAA breach: Unauthorized disclosure of PHI can trigger civil penalties and corrective action

Privacy litigation: State privacy law violations may lead to private suits or regulatory fines

Hire delays: Incomplete forms or poor workflows delay onboarding

Recordkeeping errors: Improper retention can impede defense against claims

Data integrity: Missing audit evidence weakens attribution of consent

Common mistakes to avoid when preparing the questionnaire

Asking broad pre-offer medical questions that go beyond essential job functions and may violate ADA guidelines.
Failing to obtain clear consent for collecting or sharing medical information, especially when third-party verification is required.
Storing completed questionnaires in unsecured locations or without access controls, increasing the risk of unauthorized disclosure.
Omitting audit details such as signer identity, timestamps, and IP address that support the authenticity of electronic signatures.

Timing considerations, regulatory triggers, and recommended response windows

Manage timelines so medical screening occurs after a conditional offer and documentation meets federal employment and identity-verification deadlines.

Post-offer timing:

Conduct medical inquiries only after a conditional offer is made; do not request before offer stage

Candidate response window:

Recommend return within 7 days to avoid onboarding delays

I-9 completion:

I-9 must be completed within 3 business days of hire (8 CFR §274a.2)

E-sign consent retention:

Retain consent evidence per ESIGN recordability requirements

HIPAA incident reporting:

Report breaches per HIPAA and state rules when PHI is exposed

eSignature vendor pricing and feature snapshot for medical questionnaires

Compare base pricing and key features relevant to securely collecting health information and maintaining audit trails across vendors.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about post-offer medical questionnaires

Answers to common operational and legal questions about using, signing, and storing Employment Post Job Offer Medical History Questionnaires.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and generally under UETA in most states; ensure the signer demonstrates intent, consents to electronic records, and that record reproduction is possible.
Is medical information in the form protected by HIPAA?
Only when the employer is a HIPAA-covered entity or the data qualifies as protected health information handled by a covered entity. In many employment contexts ADA confidentiality and state privacy laws apply; treat data as sensitive and restrict access.
What if a candidate refuses to complete the questionnaire?
Refusal may prevent finalizing a conditional offer when the questionnaire is a lawful condition of employment; however, employers must avoid discriminatory follow-up and consider whether accommodations or alternative evaluations apply under the ADA.
Who should have access to completed forms?
Limit access to HR and occupational health personnel on a need-to-know basis. Store medical information separately from general personnel files to maintain confidentiality and compliance.
How do I secure electronic submissions?
Use platforms offering TLS in transit, AES-256 at rest, audit logging, and a HIPAA BAA when PHI is involved. Configure signer authentication and conditional field visibility to reduce exposure.
How long must completed forms be kept?
Retain records consistent with federal standards and industry rules: at least 3 years for employment-related records, and 6 years when HIPAA applies (45 CFR §164.530(j)); check state statutes for longer retention requirements.

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