MEDICAL HISTORY QUESTIONNAIRE
To the Applicant: The employer has made you an offer of employment, conditioned on the satisfactory completion of this questionnaire and, if the
employer deems it necessary, on the results of a medical examination. The purpose of this inquiry is to determine whether you currently have the
physical or mental qualifications necessary to perform the job that has been offered, whether and what accommodations may be necessary, and
whether you can perform the job without posing a direct threat to the health or safety of yourself or others. (An examination will be required only if it is
required for all other applicants for the same job category or your response to questions indicates need for physician opinion as to whether or not you
should be able to perform the duties of the position. The cost of the examination would be borne by the employer.)
1. Do you currently have a contagious disease or infection that would pose a significant risk of transmission to
others and that could not be accommodated by postponing your employment starting date? Yes No
If yes, explain.
2. Do you have any physical or mental disabilities that would prevent you from performing the essential
functions of the job you have been offered with or without reasonable accommodation and in a
manner that does not pose a direct threat to yourself or others? Yes No
If yes, explain.
3. Do you require any accommodations to physical or mental disabilities in order to perform the essential
functions of the job you have been offered? Yes No
If yes, explain.
4. Do you currently use illegal drugs and/or lawful drugs or controlled substances that affect your ability to
perform the essential functions of the job you have been offered, with or without reasonable
accommodation and in a manner that does not pose a direct threat to yourself or others?
Yes
No
If yes, explain.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any
genetic information when responding to this request for medical information. “Genetic information” as defined
by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic
tests, the fact that an individual or an individual’s family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully
held by an individual or family member receiving assistive reproductive services.
The District may be entitled to medical verification of any asserted disability and/or medical condition and related
restrictions. Under state and federal law, both the employer and employee are expected to engage in an ongoing
“interactive” process to determine the nature and extent of the restrictions and reasonable accommodations.
The District will comply with all legal obligations in regard to your employment, including an obligation to
reasonably accommodate protected disabilities.
I hereby certify that the above statements are true, to the best of my knowledge, and that any intentional misstatements of
fact may result in the employer’s withdrawing its conditional offer of employment or in dismissal.
Employee: Date
Signature:
