After reviewing your job description regarding the physical demands answers the following.

Noting if there is any limitation that needs some level of accommodation:

I have reviewed the above employee Medical History and assessment. I have had the opportunity to ask questions. I understand the physical requirements of my job description .

I understand I may need to seek further medical evaluation by my physician before becoming eligible for hire in my job description.

The information provided to the agency on this form is correct, true and complete. Any false statement or omission of fact on this form may result in my dismissal.

The above information is confidential. In the event of a Worker’s Compensation claim, I also understand that any or all of this information may be submitted to BWC and/or any BWC authorized personnel regarding the claim.

I declare that I am free from any communicable disease or condition that might represent a possible hazard to the health of patients or other employees of the Agency.