Pre Employment Physical Examination Form Page 4
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4Pre-Employment Physical Examination
Section 2 Placement Recommendation (to be completed by Medical Practitioner)
Name of applicant:
Date completed:
Do you consider the above named is fit for the duties as described in the attached Job Hazard Form?
(Please circle)
Yes
No
Do you consider any further examination necessary?
Yes
No
If yes, please specify:
Any additional comments?
Signed (Audiometrist):
Printed name:
Date completed:
Name of Practice:
Address:
Contact Number:
Please ensure that all completed and signed sections are returned to as soon as possible:
Attention: [Name}
Company Name
Address
Email
Pre-Employment Physical Examination Form
Page 4 of 4
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Parent category: Medical