Certificate Of Physical Fitness/health Exam

Employee Name: ___________________________

Position: ___________________________

Geneva C.U.S.D. 304

Certificate of Physical Fitness/Health Exam

To: Employee and Physician

Requirement for Employment

Illinois School Code, Chapter 122.24-5 indicates "School Boards shall require of new employees

evidence of physical fitness to perform duties assigned and freedom from communicable disease.

Such evidence shall consist of health examination made by a physician licensed in Illinois or any

other state to practice medicine and surgery in all its branches not more than 90 days preceding

time of presentation to the board and cost of such examination shall rest with the employee."

Physician's Certificate

I certify that I have examined __________________________________ and find this person is

able to perform the duties assigned.

Physician's Signature:

Address:

Pre-school Staff Only

Tuberculum Test Results

__________ Negative

__________ Positive

Date:

physical form tb-preschool.doc

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