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Employee Physical Exam Form

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					                              PHYSICAL EXAM AT POINT OF HIRE


TO THE EXAMINING PHYSICIAN AND THE PROSPECTIVE ___________________ NONRESIDENT WORKER/EMPLOYEE:

Pursuant to ____________ , a nonresident worker and any member of the worker’s family coming to the __________
Is required to have a physical exam and screening for communicable disease at the point of hire “(home country)”. To
satisfy this requirement, the worker’s examining physician must complete this form in its entirety.

The health clearance exam at the point of hire must include a thorough physical exam, chest X-ray for Tuberculosis , a
Rapid Plasma Reagin (RPR) blood test for Syphilis, and a blood test for Human Immunodeficiency Virus (HIV). Upon entry
into the _______________, the Nonresident Worker employee and accompanying family members will be required to
undergo another physical exam and testing to verify that they are indeed free of communicable disease, and in good
health and free to work. Those Nonresident Worker employees and accompanying family members found to have a
communicable disease or who are not in good health and fit to work may be subject to deportation.

Note: The Nonresident Worker (and any accompanying family member(s) must provide the examining physician with a
photograph that must be signed by the worker (family member) in the presence of the examining physician. THE
SIGNED PHOTOGRAPH MUST BE ATTACHED TO THIS FORM.

THIS PORTION TO BE COMPLETED BY THE EXAMINING PHYSICIAN:

Procedures                    Performed                     Reviewed                      Not Performed
History and Physical exam
Chest X-ray
RPR
HIV

BASED UPON THE RESULT OF THESE PROCEDURES, THE EXAMINEE, __________________________________________
(IDENTIFIED BY THE PHOTOGRAPH SIGNED IN MY PRESENCE AND ATTACHED HERETO) IS FOUND TO BE PHYSICALLY
FIT, IN GOOD HEALTH AND FREE OF COMMUNICABLE DISEASE AS VERIFIED BY THE PHYSICAL EXAM AND TESTS
PERFORMED.



PRINTED NAME OF THE EXAMINING PHYSICIAN: ________________________________

SIGNATURE OF EXAMINING PHYSICIAN : _____________________________________                         attach photo
                                                                                                     here


NAME AND ADDRESS OF EXAMINING FACILITY:

_________________________________________________________________________

				
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Description: Sample Employee Physical Exam Form