Health Status Statement Form (Page 2 of 2) in pdf

Health Status Statement Form Page 2

TDY MEDICAL STAFFING, INC.

TDY Government Services

POST OFFER/PRE-EMPLOYMENT PHYSICAL

EXAMINATION WAIVER

I hereby request a waiver of a physical examination and release TDY Medical Staffing,

Inc. (TDY) of any and all liabilities that may thus develop due to the lack of a physical

examination. I also accept the responsibility for my physical well-being while employed

at TDY and I understand that TDY reserves the right to request a physical examination.

I further understand that if I have a pre-existing medical condition that could be or is

aggravated while employed by TDY, that it must be reported to TDY. I agree that I will

not partake in any activity which could aggravate a pre-existing medical condition.

Information provided to TDY regarding your health is to be used for the planning of

facilities and in no way affects your employment with TDY

TDY complies fully with

Section No. 504 of the Rehabilitation Act of 1973 and Americans with Disabilities Act

(ADA) of 1990.

____________________________________

___________________

Applicant’s Signature

Month / Day / Year

Last 4 digits of Social Security Number: _________________

Birthdate: ____________________

Name:

______________________________________________________________________________________________

(Last)

(First)

(Middle)

Address: ____________________________________________________ Telephone: ________________________

PLEASE READ, SIGN, COMPLETE AND FAX BACK WITHIN 3 DAYS OF RECEIPT TO 215-839-3442

Health Status Statement Form Page 2