Do you work in an area with frequent contact with blood, blood products, or blood contaminated equipment?
YES NO .These areas are considered high risk for exposure to Hepatitis B.
Hepatitis B vaccine is available to ALL employees free of charge. The vaccine is strongly encouraged for employees
who answered YES to the question above. Additional information is available at your request from the Employee
PLEASE READ CAREFULLY AND SIGN:
I have received a conditional offer of employment at Northside Hospital. I understand that all individuals receiving
offers of employment are required to complete a medical history and examination. The purpose of this
questionnaire and the examination is to determine (1) my ability to perform the essential functions of the job that I
have been offered, (2) whether I require any accommodations to perform those essential job functions and (3)
whether I can perform those essential job functions without presenting a threat to the health and safety of myself
I understand that this questionnaire and examination are for the limited purpose described above and are not
intended to provide a comprehensive screening for all medical conditions. I have been encouraged to establish a
relationship with a primary care physician to address my own healthcare needs. I release Northside Hospital and
all persons performing this limited purpose examination or obtaining such information from liability for failure to
detect or disclose any medical condition.
I understand that the federal Genetic Information Nondiscrimination Act (GINA) prohibits employers from asking
questions pertaining to genetic testing or family medical history. I have not disclosed any health condition or
potential health condition based on genetic testing or family history.
I agree to complete any necessary authorization forms to obtain information from any hospital, clinic or physician
necessary to make the determinations described above. I understand that my refusal to complete such
authorization forms may be considered cause for withdrawal of the conditional offer or discharge from
I certify that all information provided in this questionnaire is true and correct to the best of my knowledge. I
understand that any falsification or significant omission of any information requested herein can be considered
sufficient cause for discharge without prior warning at any time during my employment or assignment at Northside
I also understand that the information in this questionnaire and collected in the medical examination will be kept
strictly confidential in a separate employee health file, apart from my personnel file. The information will be
available only for the purposes authorized by the Americans with Disabilities Act, including disclosure to my
manager or supervisor on an as needed basis regarding necessary restrictions or accommodations.
I further understand that if I am injured at work and medical treatment other than first aid becomes necessary, I
must accept the services of a physician listed on the Panel of Physicians for Worker's Compensation. If I choose a
physician not listed on the Panel, I will be liable for those medical expenses.
EMPLOYEE SIGNATURE DATE
TO BE FILLED OUT BY HEALTH CARE PROVIDER:
Height Weight B/P PPD Or Chest X-Ray
Hep B Series Varivax Rubella Rubeola
Varicella Urine for Drug Screen Shown W/C Panel
Health Care Provider Signature
***If BP is >160/100 a 2
BP is required***
B/P (2) B/P Notes
COVID Vaccine (If vaccinated within the last 30 days, do not order QFT/Tspot )