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FOR OFFICE USE ONLY: DATE OF HIRE:
EMPLOYEE NO:
Medical Assessment for Employment BY PHYSICIAN AND TAKEN TO New Brunswick Hospitals Act (New Brunswick Requlation 92-84, Chapter H-6.1 1993-03 specifies that: Section 56 A person who applies to be employed by a regionat heatth authority shatt submit proof satisfactory to the regional health authority of having had a comprehensive physical examination before entering employment with the regional health authority.
The completed (2) page Medical Assessment for Employment and an appointment with the SERHA Emptoyee Health Nurse are to be completed prior to Date of Hire. All health information will remain confidential to Employee Health Services and cannot be released without the written consent of the individuat.
NAME
DATE OF BIRTH
ADDRESS
MEDICARE # PHONE #
DEPARTMENT
POSITION
Report of comprehensive medical examination
Previous surgeries, hospitalizations, or significant illnesses
List all medications
List all allergies
Urine:
Sugar
Protein
Blood
BP
Height
Weight
Food Services Emplovees Onlv: Previous history of
salmonella? Yes n
Laboratory Emplovees Onlv: Color Blindness Assessment
Pass
No
n
n Fail
ln your opinion, is employee physically and mentally capable of performing the functions of the
Date
n
job?
Yes
n
No
Please indicate any physical or mental limitations that must be considered for employment Date:
Physician's Name (print)
NOTE:
Physician's Signature
Page 1 of 2 Form # 401 - 05/09 replaces 10/08 This is a CONTROLLED document. Any document appearing in paper form is not controlled and should ALWAYS be checked against the electronic version prior to use. Printed on: 11312Q13
n