Transcription of TO: ALL STATE AGENCIES, EMPLOYEE ORGANIZATIONS, …
1 CORRECTED 8-14-02* DATE: July 10, 2002 TO: ALL STATE agencies , EMPLOYEE ORGANIZATIONS, AND MEMBERS OF THE GOVERNOR S CABINET SUBJECT: NEW MEDICAL CLEARANCE FORM (STD 910) The new Essential Functions Health Questionnaire (STD 910) is now available for departmental use for medical clearance purposes. This form was developed by the Task Force on Medical Clearance Options to simplify the collection of basic applicant information relevant to the health of persons who have been offered and accepted a STATE civil service appointment. Departments may order the STD 910 from the Department of General Services, Office of STATE Publishing, either: 1. Via the Internet (for no fee) at The order form is in pdf Fill & Print Format, which requires Adobe Acrobat Reader to view the form; or 2.
2 Through the Office of STATE Publishing, Forms Management Center (IMS-P6), 344 North 7th Street, Sacramento, CA 95814. Telephone (916) 324-4635 or (800) 964-3214. Package: Pad, Quantity: 50, Price: $ Departments may also use the Functional Ability Health Questionnaire (SPB 2066), a longer version, which is available on the STATE Personnel Board s Web site at Attached is a sample of the Essential Functions Health Questionnaire (STD 910). Questions about the STD 910 may be directed to Jerry W. Donel at (916) 653-1717 or TDD (916) 653-1498. Medical questions may be directed to Stephen G. Weyers, , at (916) 653-0790 or TDD (916) 653-1498. Mike Willihnganz Chief, Policy Division Attachment (STD 910) *The original July 10, 2002 memo contained an incorrect Web site.
3 The correct Web site for Item No. 1 above is
