Fillable Pre-employment Physical Questionnaire

Fill Online, Printable, Fillable, Blank Pre-employment Physical Questionnaire Form

Use Fill to complete blank online CITY OF BANGOR (ME) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Pre-employment Physical Questionnaire

On average this form takes 5 minutes to complete

The Pre-employment Physical Questionnaire form is 1 page long and contains:

  • 0 signatures
  • 30 check-boxes
  • 7 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Bangor

BROWSE CITY OF BANGOR (ME) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Pre-employment Physical Questionnaire
Department of Safety and Environmental Management
Created: 9/5/17
Revision: New 1 | Page
This questionnaire is designed to help the City of Bangor identify and document the specific pre-employment physical
examination or testing required before hiring a new employee for the position listed below. The information provided by the
Supervisor will be shared with the City’s occupational medical provider.
Department:
Job Title:
Will this position be required to:
Yes No 1. Lift heavy objects?
a. > 25 lbs.
b. > 50 lbs.
c. > 75 lbs.
d. Other? _________________________________________________________________
2. Repetitively lift objects during a work shift?
3. Lift objects while stooping or bending over?
4. Stand for a majority of the work shift?
5. Repetitively perform a specific movement or group of movements during a work shift?
6. Reach for or lift items above shoulder height?
7. Frequently use vibrating tools or equipment?
8. Perform a task that would require the use of a respirator (i.e. N95, ½ mask, SCBA, etc…)?
Will this position be or could potentially be exposed to: Yes No
1. Loud noises?
2. Human blood or other potentially infectious materials (OPIM)?
3. Tuberculosis?
4. Organophosphate or Carbamate pesticides?
5. Metal particulates or fumes?
List any other exam that is provided for this position, but may not have been captured in the previous
questions:
Comments:
Completed By:
Date:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Pre-employment Physical Questionnaire

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document