HEALTH STATUS QUESTIONNAIRE

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HEALTH STATUS QUESTIONNAIRE Powered By Docstoc
					                                        HEALTH STATUS QUESTIONNAIRE
As a conditional offer of employment, affiliated contracting status, professional staff membership, and/or
the exercise of clinical privileges at a KFH facility you are required to demonstrate that your health status
is such that you can competently and safely perform the essential functions of the position, with or without
reasonable accommodation. Please provide responses to the following questions. Any "yes" answer(s)
will not automatically result in an adverse credentialing or employment decision. Please provide a
detailed factual description and explanation of all "yes" answers. Attach additional sheets as necessary.

          1.        Do you have any physical or mental condition that would interfere with or limit your
                    essential functions or professional responsibilities or in any way impose a risk of harm to
                    patients, members, staff members, or yourself?

                               Yes       No       If yes, please explain and describe any reasonable
                    accommodation that you would require to perform the duties of position that you have
                    been offered.

          2.        In the past five years, have you been dependent upon alcohol or drugs?

                                  Yes          No    If yes, please explain.

          3.        In the past five years, have you been treated for dependency upon alcohol or drugs?

                                  Yes          No    If yes, please explain.

          4.        Are you participating in a supervised rehabilitation program, diversion program or
                    professional assistance program which monitors you in order to assure that you are not
                    engaging in the use of alcohol or controlled substances?

                                  Yes          No    If yes, please explain.

I hereby affirm that the information provided in this questionnaire is accurate and fairly represents my
current health status. I understand that any misrepresentations, misstatements or omissions in this
questionnaire, whether intentional or not, will constitute cause for automatic and immediate rejection or
denial of my application. If I have begun work prior to the discovery of such misrepresentation(s),
misstatement(s) or omission(s), such discovery may result in immediate suspension or termination of
employment, affiliated contracting status, professional staff membership and/or clinical privileges with
Kaiser Permanente.



APPLICANT’S SIGNATURE                                                                  DATE


PRINT NAME


                                        Request for Additional Information

In order to obtain information from sources such as the National Practitioner Data Bank, American
Medical Association and Federation of State Medical Boards the following information is required:


                                               Gender:           Male             Female
          Date of Birth




CONFIDENTIAL DOCUMENT
Revised and Approved by RCPC 09/09/05

				
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