W
DEPARTMENT OF HUMAN RESOURCES
ENTRANCE MEDICAL EXAMINATION
I, ________________________________, having been given a conditional offer of employment
for the position of _____________________________________ do hereby authorize the
College of Wooster to set an appointment for a medical examination to certify my physical
ability to complete the essential functions of this position.
If the medical examination reveals that I have a physical condition, that condition will only be
used as a basis for withdrawing the job offer if:
1. The condition prevents me from performing the essential functions of the job; or
2. I would pose a direct threat to my own safety or that of others because of the condition.
I understand and agree to completely release and absolve the College of Wooster and its staff
members from all liability connected in any manner, either directly or indirectly, with this
examination. Should I desire a copy of this medical report, it may be obtained from the Center
for Occupational Medicine.
I also understand that termination of employment for any reason within the first 90 days of
employment will result in the cost of the physical and/or back test being deducted from my last
paycheck. If the check does not cover the full amount, I will be billed for the remainder.
Signature __________________________________________
Date ______________________________________________
Signed in the presence of:
Witness ___________________________________________
This process is in compliance with the provisions of the Americans with Disabilities Act, Public
Law 101-336.
1/03 H.R.O.
