To the Employee completing this form: Your confidentiality is protected in accordance with public law. Neither supervisors nor any other City employee are provided with your individual information. Note: Form must be signed and dated to be valid.
You may be contacted by The Work Clinic if there are questions about your responses to this questionnaire.
Without complete information RESPIRATORY MEDICAL CLEARANCE may be delayed or may not be issued.
2. Have you ever had any of the following condition?
3. Have you ever had any of the following pulmonary or lung problems?
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
5. Have you ever had any of the following condition?
6. Have you ever had any of the following cardiovascular or heart symptoms?
7. Do you currently take medication for any of the following problems?
8. If you have used a respirator, have you ever had any of the following problems?
2. Do you currently have any of these vision problems?
4. Do you currently have any of these hearing problems?
6. Do you currently have any of the following musculoskeletal problems?