Diversity Information Page 20
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26 Graduate Medical Education Pre‐Employment Health Evaluation
Prior to your contract start date, but no sooner than 30 days in advance, you must complete and pass
a Pre‐Employment Health Evaluation, including drug screening and TB testing (requires you to return
two days later). You are NOT eligible to start your training until this has been completed.
To schedule your Pre‐Employment Health Evaluation, please complete this form to indicate
your preferences for an appointment. Return this form to the HFH GME Office. The GME
Office will send confirmation of the date and time of your appointment, with further
instructions.
Name: (Last, First)
Email Address:
Social Security Number:
Date of Birth (DOB):
Children are NOT ALLOWED in the Employee Health Center; please plan accordingly. Remember that
you must be able to return two days later to have your TB test read. Please select a date within 32 days
of your contract start date and time between 8 and 11 a.m. or 1 and 4 p.m. Indicate your first (1) and
second choices (2) for date and time:
Choice
Date
Time
Choice
Date
Time
Monday, May 20
Monday, June 10
Tuesday May 21
Tuesday June 11
Wednesday May 22
Wednesday June 12
Friday, May 24
Friday, June 14
Tuesday May 27
Monday, June 17
Wednesday May 29
Tuesday June 18
Friday, May 31
Wednesday June 19
Friday, June 21
Monday, June 3
Monday, June 24
Tuesday June 4
Wednesday June 26
Wednesday June 5
Friday, June 28
Friday, June 7
Monday, July 1
Preferred Employee Health Center:
Henry Ford Hospital, Detroit Main Campus
Henry Ford West Bloomfield Hospital
IF you are unable to keep your appointment because of circumstances beyond your control, OR
IF you are unavailable on any of the dates listed, please contact Employee Health at 313‐916‐4820,
Option 1,.
v. 2/15/13
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