Consent to Physical Exam

VIEWS: 1,757 PAGES: 3

More Info
									This is a document that can be used by a company to obtain consent from an employee
to undergo a physical examination. The physical exam is required because the
employee’s position requires strenuous physical activity and ensures the safety of the
employee and other employees. Additionally, the employee has the right to obtain a
copy of the written evaluation after it has been directly sent to the company. This
document should be used by small businesses that require employees to undergo
strenuous physical activity and want to conduct physical examinations to ensure safety.
    In connection with my Application for Employment with _____________________
[Instruction: insert the name of the employer] (the “Company”), I, _____________,
[Instruction: insert the name of the employee] a current employee of the Company, hereby
agree to the following:

1. I recognize that my position requires a significant amount of strenuous physical activity. I
   understand that a physical examination is necessary to assess my fitness level for the
   requisite functions of my job. In consideration for my own safety and the safety of my
   colleagues, I give my consent for the Company to conduct any physical examinations it
   considers appropriate.

2. I retain the right to ask questions at my physical examination, and I retain the right to receive
   a copy of the written evaluation concerning my fitness to perform the essential functions of
   my current job. I retain the right to stop the physical examination at any point, but with an
   understanding that such an act may jeopardize the status of my employment.

3. I authorize medical personnel retained by the Company to perform the physical examination
   to release the results to the Company. Further, I release the medical personnel conducting
   the examination, the Company, and the Company’s employees, directors, and officers, from
   any liabilities, claims, and causes of action, known or unknown, that may result from any
   such physical examination. I agree not to file any lawsuit or other action to assert any such

   I have read and understood this Physical Examination Consent and I execute same of my
own free will, without any coercion or duress by any individual or institution.


____________________ [Instruction: insert the name of the employee]


© Copyright 2013 Docstoc Inc.                                                              2

To top