NURSEPARTNERS
HEALTH, SAFETY AND COMPLIANCE QUESTIONNAIRE
Your safety on
the job is important to NURSEPARTNERS. By answering the following questions you
will enable us to offer you assignments which you will be able to perform
safely!
NURSEPARTNERS is an equal employment opportunity employer and complies with all handicap and disability discrimination laws.
1. Have you ever had an
injury, suffered from or been treated for a condition involving:
__ Back/Neck/ Shoulder
___ Hand/Wrist/Finger ___Headache/Eye
Strain _____Other Condition
___ None
a. Check if the injury involved: ____
Sprain _____Bone Fracture
___Bruise ___Cut
___Carpal Tunnel Syndrome/ Tendonitis
b. Will any of the above checked injuries or conditions interfere with your
ability to safely perform any of the job activities shown in the Physical
Activities section below?
___No
___ Yes (Explain: _________________________________________)
c. Would performance of any of the job activities listed in the physical
activities section below be likely to aggravate a pre-existing health or medical
condition?
___No
___Yes (Explain: _________________________________________)
2. Have you ever received worker’s compensation benefits for
any of the above injuries?
___No
___Yes Year: _________ State:
__________
3. Do you need an accommodation (covered under the Americans
with Disability Act) to successfully do the work for which you have qualified?
___No
___Yes (Explain: _________________________________________)
4. Are you currently taking any medication which may cause drowsiness, slow
reflexes / reactions or affect your ability to work safely?
___No
___Yes (Explain:__________________________________________)
PHYSICAL ACTIVITIES SECTION: Check all activities affected by any injury or condition indicated above.
Repeated Act: ___Lifting/Moving ___Bending/Stooping ___Stretching/Reaching __Standing/walking ___Hand/wrist motion
Operation of: ___Machine/Equipment ___Motor Vehicle ___Video Display Terminal
Performing: ___ Close inspection or detail work
I certify that NURSEPARTNERS offered me employment and conditioned the offer on NURSEPARTNERS ability to safely assign me based on the information I have provided. I further certify that the above information I have provided is complete and accurate. I agree to promptly notify NURSEPARTNERS if any of the information above changes.
VERIFIED BY NURSEPARTNERS REP: _______________________ DATE: __________________
COMPLIANCE:
Have you ever been convicted of a felony or misdemeanor in the USA? Y N
By signing below, I also agree to be tested for alcohol, illegal drugs, or
other potentially intoxicating substances prior to an assignment, and/or if I
am involved in an incident resulting in an injury to me or anyone else while
on assignment for NURSEPARTNERS . I
further authorize NURSEPARTNERS to
check my worker’s compensation history and conduct
a criminal background investigation as required.
Employee Signature:
_______________________ Date:
______________________