Form Dhcs 5105 - California Staff Health Questionnaire - Health And Human Services Agency

State of California — Health and Human Services Agency

Department of Health Care Services

Licensing and Certification Branch, MS 2600

PO Box 997413

Sacramento, CA 95899-7413

STAFF HEALTH QUESTIONNAIRE

(Outpatient Facilities Only)

All staff and volunteers whose functions require or necessitate contact with participants or

food preparation shall complete a health questionnaire.

Name:

Job Title:

1. Do you have any serious health problems or illnesses that may be contagious to others around

you?

Yes

if yes, please give details:

2. Do you have limitations on your ability to perform the work described in your job description

and/or duty statement?

Yes

if yes, please give details:

Do you have any health conditions that would create a hazard to participants or other staff?

Yes

if yes, please give details:

I declare that the above information is true and correct to the best of my knowledge:

EMPLOYEE SIGNATURE

DATE

DHCS 5105 (07/13)

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Parent category: Legal