Advanced Mechanical Services

Commercial HVAC & Refrigeration

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Health Questionnaire & Drug Use Info

"*" indicates required fields

To be completed after an employment offer is made and before the employee begins work.

This medical information is being gathered in compliance with the Americans With Disabilities Ace (ADA) and will be maintained in a separate medical file as a confidential medical record, except that supervisors/managers may be informed about necessary work restrictions and accommodations; first-aid/safety personnel may be informed of any necessary information for emergency medical treatment; and the government may be provided with this information when enforcing the ADA. 42 USCA § 12112(d) (3) (West 2008)

In addition, the employer reserves the right to use this information to assist in presenting a workers’ compensation claim for reimbursement under any Subsequent/Second Injury Trust Fund. 29 C.F.R § 1630.14(b) (West2008)

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Employee Name*
MM slash DD slash YYYY
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Please check each of the following health conditions you have experienced.*
Have you ever received medical care or surgery for any of the conditions listed above?*
Have you ever been hospitalized for any of the conditions listed above?*
Are you presently receiving care or have you received care during the past year for any of the conditions listed above?*
Are you currently receiving treatment or have you ever received treatment for a medically diagnosed mental illness or disorder such as depression, manic depressive condition, anxiety, schizophrenia, or any similar or related condition?*
Are you currently receiving treatment or have you ever received treatment for an alcohol or drug condition?*
Do you have any physical condition which we should be aware of in the event of a medical emergency?*

Drug Use Information

Check all the medications, pills, drugs, or other substances you have used within the past 3 days. This information will be used to help interpret the results of your blood and /or urine test.*
Consent*
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