NOTICE TO APPLICANTS: In compliance with the Americans with Disabilities Act of 2008 (ADA), you have received a conditional offer of employment. This medical history statement is required of all offerees. The answer to the medical history statement and any medical examination will be kept confidential and in separate files in compliance with the ADA requirements. The job offers which you have received is conditioned upon satisfactory completion and review of this medical history statement and any required medical examination or follow up.
GENETIC INFORMATION NONDISCRITMATION ACT (GINA) OF 2008: Title II of the GINA prohibits employers and other entities by GINA Title II from requesting or requiring genetic information of employees or their family members. To comply with this law, we are asking that you not provide any genetic information when responding to a request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member and genetic information of an embryo lawfully held by an individual or family member receiving assistive reproductive services.
APPLICANT AFFIRMATION: I herewith affirm that the employer has made me an offer of employment, conditioned on the satisfactory completion of this questionnaire and any required medical examination or follow-up. The purpose of this inquiry is: to determine whether I currently have the physical qualifications necessary to perform the job that has been offered; to determine whether and what accommodations may be necessary; and to determine whether I can perform the essential functions of the job, without posing a significant direct threat to the health and safety of myself and others. This information will be kept strictly confidential in a separate medical file, apart from my personnel file. I hereby affirm that the questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job.
4. Have you ever had or been treated for any of the following conditions or disease?
The above statements are true to the best of my knowledge. I understand that any misstatement of fact is grounds for disciplinary actions up to and including termination. I further understand that any willful misrepresentation of any medical condition can serve to bar any future claim for workers’ compensation benefits.
