Medical Questionnaire

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Name*
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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.*

Post- Offer Medical Questionnaire Continued - Part 1

Do you now have, or have you ever had, any of the following:

Post- Offer Medical Questionnaire Continued - Part 2

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.

Post- Offer Medical Questionnaire Continued - Part 3

If so, please provide the reason and the percentage of impairment. If you have not been given an impairment rating, state “none.”
If yes, please list the medications. If you are not taking any medications, state “none.”
The above statements are true to the best of my knowledge. I understand that any misstatement of fact is grounds for disciplinary action up to and including termination. I further understand that any willful misrepresentation of any medical condition can serve to bar any future claim for workers’ compensation benefits*
Electronic Signature*