417 Exh. A – Physical Form

URBANDALE COMMUNITY SCHOOL DISTRICT

Name of Person Examined:______________________________________________________________

Address:______________________________________________________________________________

Social Security Number:________________________________________________________________

Position:______________________________________________________________________________

Building:_____________________________________________________________________________

I certify that he/she o is, o is not, fully qualified in health to perform the assigned duties of the position listed above.

Additional remarks:____________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

____________________________

____________________________
Name of Examining Physician, Address
Chiropractor, Licensed

 

____________________________
Physician Assistant, or
Advanced Registered Nurse
Practitioner

____________________________

____________________________
Signature of Examining Physician,
Date of Examination

Chiropractor, Licensed Physician
Assistant, or Advanced Registered
Nurse Practitioner

Return to:

Director of Human Resources
Urbandale Community School District
6200 Aurora Avenue, Suite 500W
Urbandale, IA 50322-2838

Form Revised: February 20, 2012

URBANDALE COMMUNITY SCHOOL DISTRICT BOARD OF DIRECTORS

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