Pre-Employment History And Physical Form Page 3
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4Occupational Assessment
Please answer the following questions regarding the job for which you have been hired:
Yes
No
Unsure
Will you be required to wear respiratory protection (e.g., N95 mask or cartridge respirator)?
Do you anticipate working with hazardous chemicals or materials, infectious agents, or laboratory animals?
Is there a chance that you will be exposed to human blood or body fluids as a result of routine job duties?
If your job involves work at a computer, have you had or are you experiencing any discomfort, pain, or
numbness when working at your desk?
Will you be required to drive a vehicle for any reason?
Will you be required to move heavy objects regularly (i.e., greater than 50 pounds occasionally or 25 pounds
frequently)?
Have you ever had an occupational injury/illness before (e.g., back strain, needle-stick, chemical exposure)?
Do you have any condition (physical, medical, or psychological) that would require special
accommodations in order for you to perform your job?
Yes
No
(if yes, please specify on next lines)
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Signature of employee: ____________________________________________
Date: __________________
Practitioner Notes: __________________________________________________________________________
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Parent category: Medical