Your answers will be considered only to the extent that they are related to your ability to safely perform your assignment/contract. Some answers may require a physician's release to work.
1. Do you have any condition or impairment that prevents you from performing the essential functions of the position you have been hired to fill? Yes No
2. Do you have any health conditions that may be of potential risk to patients/residents/students with whom you may come into contact while working in the position you have been assigned or contracted to perform? Yes No
The preceding answers are true to the best of my knowledge and ability. I understand this will be part of my personnel health file, and that falsifying answers could lead to disciplinary action, up to and including termination.
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Document Name: Health Self-Assessment - Favorite
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