Fitness for Duty Attestation
The purpose of this attestation is to ensure you have the physical and cognitive ability to safely perform the duties of your job.
Name
*
First Name
Last Name
Please indicate your responses to ALL 4 QUESTIONS below, adding any remarks in the space provided. Please note that your responses to questions and signature indicate you have the physical and cognitive ability to safely perform the duties of the job in a safe, secure, productive, and effective manner.
Do you currently have a problem associated with the use or misuse of drugs or controlled substances of any kind (whether obtained by prescription or otherwise) or alcohol that has the potential to affect your ability to safely perform the essential functions of your job?
*
Yes
No
Remarks
Are you currently on any medication(s) that may affect either your clinical/professional judgment or motor skill, and therefore, your ability to perform the essential functions of your job?
*
Yes
No
Remarks
Do you currently have any workload or activity limitation(s) which would affect your ability to perform the essential functions of your job, including, without limitation, your ability to fulfill your obligation to provide on-call coverage, as assigned?
*
Yes
No
Remarks
Are you currently under the care of a physician or psychologist, or currently in any mandated recovery program established pursuant to a state or other state that would prohibit your ability to perform all the services required by your employment agreement, position description, and/or participation agreement of the Health Center to which you are applying or renewing, with or without reasonable accomodation, according to accepted standards of professional performance and without posing a direct threat to the safety and security of patients?
*
Yes
No
Remarks
Based on your responses above, once you submit, your form will be forwarded to HR for a consultation. Please follow up with HR for next steps at stowsley@liberty-resources.org.
Signature
Submit
Should be Empty: