Inquiry Authority/use Statement Mapep Form 2006
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1
2GENERAL INFORMATION
MEDICAL AND PHYSICAL EXAMINATION PROGRAM
(MAPEP)
Inquiry Authority/Use Statement
The collection of this information is authorized by O.C.G.A. 45-2-40. This information will be used to determine fitness for
duty and to provide protection to employees from potential harmful effects associated with this employment. Unless otherwise
stated, this information may be disclosed to the hiring agency, State agencies responsible for State benefits and workers’
compensation programs, and, where pertinent, to an appropriate law enforcement agency for investigation for prosecutive
purposes or in a legal proceeding to which the hiring agency is a party. As provided by the Americans with disabilities Act of
1990 (Public Law 101-336), this information is to be filed separately from other personnel records and is to be used only for
legitimate, non-discriminatory hiring and placement purposes with reasonable accommodation, where appropriate. Completion
of this form is voluntary; however, if this information is not provided, the individual may not receive the requested benefits or
employment.
A: Completed by Employee
1. Employee Name: ____________________________________________________
2.________-_______-_________
Last
First
Middle
Social Security Number
□
□
3. Race _________________
4. Sex:
Female
Male
5. ______________
6. _________________________
Date of Birth
Daytime Telephone Number
7. Address: ______________________________________
8. Position Title: _______________________________
______________________________________________
9. Position Number: ____________________________
______________________________________________
10. Location of Position: _________________________
11. Direct Contact for Position Information
a. Name:_______________________
f..
Dept.: _________________________________________
b. Title:________________________
g.
Unit: __________________________________________
c. Telephone: ___________________
h.
Address: ______________________________________
d. E-Mail: ______________________
______________________________________
e. Fax Number: __________________________
______________________________________
______________________________________
12. Have you been provided detailed information on the duties of this position?
□ Yes □ No
13. Do you understand the functional requirements and environmental factors of this position?
□ Yes □ No
14. Are you capable of performing the duties and responsibilities of this position (with reasonable
□ Yes □ No
accommodations, if necessary, as described in Section A, Item #17)?
For the following questions, explain a "Yes" answer in the space provided below
15. Have you ever been employed by the State of Georgia?
□ Yes □ No
16. Have you had a physical examination for employment with the State of Georgia within the past
□ Yes □ No
twelve month period?
17. Is there anything in your past medical history, of which you have knowledge that would prevent
□ Yes □ No
your being able to perform the duties of this position?
MAPEP 10-51-03 (2006)
Page 1
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