Employee Information

  • Employee Information

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  • EMERGENCY CONTACT INFORMATION

  • RELEASE AUTHORIZATION

  • 1) In connection with my application for employment, I understand that a consumer report or an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my workers' compensation injuries, driving record, court record, education, credentials, credit, and references. As company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.


    2) Medical and workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a Consumer Reporting Agency. If so, I will be notified and given the name and address of the agency or the source that provided the
    information.


    3) I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state and county agencies.


    4) I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by Cramer and Associates, Inc. or its agent, to furnish the information described in Section 1.


    5) I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer to Cramer and Associates, Inc. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released by my previous employer is limited to the following DOT-regulated items: alcohol tests with a result of 0.04 or higher, verified positive drug tests, refusals to be tested, other violations of DOT agency drug and alcohol testing regulations, information obtained from previous employers of a drug and alcohol rule violation and any documentation of completion of the return-to-duty process following a rule violation.

    Please provide the following information required by law enforcement agencies and other entities for positive identification purposes when checking public records.

  • CONDITIONAL JOB OFFER AND MEDICAL REVIEW

    Based on qualifications presented on your application form, and/or in your job interview, you arehereby offered a job with our organization conditional upon submitting to our standard medicalreview and the verification of your answers to the following questions. Your job offer cannotand will not be rescinded unless a medical review reveals that you cannot perform the essentialfunctions of the job (with accommodations if requested), or you present a hazard to yourself orothers. False or misleading statements are also grounds for rescinding this offer. Please notethat workers' compensation benefits in some states may also be affected by false or misleadinginformation. This form must be accurate and complete for us to process. This information isconsidered personal and medical in nature and will be treated as such by handling itconfidentially in strict compliance with the American Disabilities Act. This offer is valid only ifthe last page of this section is signed by a company representative.

  • HEALTH AND SAFETY

    List each incidence separately. If the answer is no, move to the next section. If you need more space, use the comment section at the end.

  • Incident 1:

  • Incident 2:

  • Incident 3:

  • HEALTH AND SAFETY (continued)

    List each incidence separately. If the answer is no, move to the next section. If you need more space, use the comment section at the end.

  • Incident 1:

  • Incident 3:

  • Incident 2:

  • HEALTH AND SAFETY (continued)

    List each incidence separately. If the answer is no, move to the next section. If you need more space, use the comment section at the end.

  • Medication 1:

  • Medication 2:

  • Medication 3:

  • HEALTH AND SAFETY (continued)

    List each incidence separately. If the answer is no, move to the next section

  • AFFIRMATION AND AUTHORIZATION

  • I hereby affirm that the information on this form is true and correct, and that there are no omissions, false information, or misrepresentation of facts. I authorize any physicians, medical facility, law enforcement agency, administrator, state agency, institution, information service bureau, insurance company, or employer contacted by this company or an agent of this company to furnish or verify workers' compensation information and medical records.I further acknowledge that a telephone facsimile (FAX) or photographic copy shall be as valid as the original.

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