Post-Offer Medical Questionnaire

Employee Name *

First Name Last Name

Today's Date *

Date

Date of Birth *

Date

Social Security # *

(example: 999-99-9999)

Height *

(example: 5' - 11" / Five Feet & Eleven Inches Tall)

Weight *

(example: 180 lbs

a partner of Rock Staffing.

NOTICE TO OFFEREES: In compliance with the Americans with Disabilities Act of 2008 (ADA), you have received a conditional offer of employment. This medical history statement is required of all offerees. The answers to the medical history statement and any medical examination will be kept confidential and in separate files in compliance with the ADA requirements. The job offer, which you have received, is conditioned upon satisfactory completion and review of this medical questionnaire and any required medical examination or follow up.

GINA DISCLOSURE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information” includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

EMPLOYEE AFFIRMATION: I herewith affirm that the employer has made me an offer of employment, conditioned on, among other things, the satisfactory completion of this questionnaire. The purpose of this inquiry is as follows: (1) to determine whether I currently have the physical qualifications necessary to perform the essential functions of the job that has been offered; (2) to determine what accommodations, if any, may be necessary for me to perform the essential functions of the job; and (3) to determine whether I can perform the essential functions of the job without posing a significant direct threat to the health and safety of myself and others. This information will be kept strictly confidential in a separate medical file, apart from my personnel file. I hereby affirm that the questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job. The conditional job duties have been adequately described to me, and I have had an opportunity to ask questions regarding the duties.

Please Complete the Following Medical Information:

Have you ever had?

Asthma *

YES NO

Migraine Headaches *

YES NO

Head Injury or Injuries *

YES NO

Fear of Heights *

YES NO

Heart Trouble *

YES NO

Fainting Spells or Dizziness *

YES NO

Swelling of the legs or ankles *

YES NO

Skin rash or Eczema *

YES NO

Joint Pain or Arthritis *

YES NO

Epilepsy *

YES NO

Cancer *

YES NO

Varicose Veins *

YES NO

Sickle Cell Anemia *

YES NO

Tendonitis *

YES NO

Repetitive Motion Disorder *

YES NO

stiffness of major weight-bearing joints *

YES NO

Kidney Problems *

YES NO

Injury to your knee *

YES NO

Injury to your back *

YES NO

Hay Fever *

YES NO

Diabetes *

YES NO

Color Blindness *

YES NO

Any amputations (foot, leg, arm or hand) *

YES NO

Loss of sight of one or both eyes *

YES NO

Cerebral Palsy *

YES NO

Multiple Sclerosis *

YES NO

Parkinson's Disease *

YES NO

Cardiovascular Disorder *

YES NO

Tuberculosis *

YES NO

Mental Retardation *

YES NO

Hemophilia *

YES NO

Chronic infection of bone *

YES NO

Muscular Dystrophy *

YES NO

Ruptured Disc *

YES NO

Nervous trouble or treatment *

YES NO

Depression *

YES NO

Injury to Neck *

YES NO

Injury to your wrist or hands *

YES NO

Please explain, if you responded to 'YES' to any of the conditions listed above:

If you answer 'NO' to any question below, you are saying you have NOT experienced pain, discomfort or injury to that particular body part and have NOT sought treatment from a medical professional.

Do you have partial loss of hearing? *

YES NO

Have you ever had an audiogram (hearing test)? *

YES NO

Do you need glasses to read or for driving/operate an auto or machinery? *

YES NO

Any wrist, arm or elbow problems including Carpal Tunnel Syndrome? *

YES NO

Any broken bones? *

YES NO

High blood pressure? *

YES NO

Any serious injuries? *

YES NO

Any hernia or rupture? *

YES NO

Any neck pain and/or neck problems? *

YES NO

Any back pain or injuries? *

YES NO

Surgeries? *

YES NO

Have you ever refused surgery? *

YES NO

Any allergic reaction(s) to any drugs? *

YES NO

Partial loss of uncorrected vision of more than 75% bilaterally? *

YES NO

Psychoneurotic Disability following confinement for treatment in a recognized medical or mental institution for a period in excess of six months? *

YES NO

Have you participated in taking illegal drugs in the past 6 months? *

YES NO

Do you currently take any medications? *

YES NO

Do you have any conditions or have you sustained any injury that would have an effect on your capacity to perform the duties of this position without reasonable accommodations? *

YES NO

Have you ever been treated for back pain? *

YES NO

Have you ever been treated for neck pain? *

YES NO

Have you ever been treated for hand pain? *

YES NO

Have you ever been treated for mental conditions? *

YES NO

Sensitivity to dust? *

YES NO

Inability to perform certain motions? *

YES NO

Inability to assume certain positions? *

YES NO

Please explain, if you responded to 'YES' to any of the conditions listed above:

List all medications that you are taking:

IMPORTANT: Our Workers Compensation Insurance carrier may check for previous claims by name and social security number. If you have had a previous claim or injury, and fail to make it aware to us, you may be legally denied benefits. For your own protection, please make us aware of any previous injuries.

Name

First Name Last Name

My signature certifies that all facts and representations made by me are true, accurate and made willingly and intentionally. *

Clear

Post-Offer Medical Questionnaire

AUTHORIZATION and eSIGNATURE