Transcription of PRE -EMPLOYMENT PHYSICAL OCCUPATIONAL HEALTH …
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PRE -EMPLOYMENT PHYSICAL OCCUPATIONAL HEALTH …
PRE -EMPLOYMENT PHYSICAL . OCCUPATIONAL HEALTH QUESTIONNAIRE. Print Form, Complete All Questions Last Name: First Name: MI: Date of Birth: SSN (last 4 only): C Male C Female Address: Street City State Zip Email Address: Phone Number: Position Applied For: Hiring Department: I have reviewed the description of the job for which I am applying. X Signature Date Do you have any condition, illness, injury, or are taking any medication that affects any of the following job related abilities for your position as identified in your job description? (Please answer ONLY the specific questions below that relate to the essential functions of the job for which you are applying, as outlined in your job description.). VISION. Do you have any impairment of vision, which is not correctable? Yes No Please explain HEARING. Do you have any impairment of hearing, which is not correctable?
Hepatitis B Vaccine I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. (Please check appropriate box) I would like to receive the Hepatitis B Vaccine. Hepatitis B Vaccine Declination (mandatory)
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