KAISER PERMANENTE

Kaiser-On-the-Job

EMPLOYER’S REQUEST FOR OCCUPATIONAL HEALTH SERVICES

Pre-Employment Instructions: Take this form and a picture I.D. to the clinic location indicated within 48 hours from the date and time listed below (Failure to do so eliminates you from further consideration for the position):
Candidate/Employee Information:
Date/Time Passport Issued: / KP Member: Y / N
Name: / sex: / Male / Female
(First) (Middle Initial) (Last) / (Maiden if applicable) (circle one)
Address: / Phone #
Social Security Number
(Last Six Digits Only) / CDL/Photo I.D. Number / I.D. Type / D.O.B.
Appointment Date: / Appointment Time:
Company Name: / Stanislaus County / Kaiser MRN:
Department Name: / Area Agency on Aging/Vet Serv. / Department Contact
Phone: / Fax:
Fund/Org: / 1051/31100 or 0100/321100 / Other:

Drug Screen Mandatory For All New Hires

Account Clerk I, II, III
Accountant I, II, III
Administrative Clerk I, II, III, IV
Community Health Worker
Confidential Assistant I, II, III, IV, V
Director Area Agency on Aging
Required Examination:
PP1 / Family Services Specialist I-IV, Supervisor
Manager I, II, III, IV
Social Worker I, II, III, IV
Staff Services Coordinator, Analyst, Technician
Veterans Service Representative
Optional Services:
Ergonomic Evaluation by PT
Kaiser Scheduling/Special Instructions:
Fax all results to Department Contact at - and to the Disability Management Unit at (209)525-5779. Any notice of unqualified, or qualified with accommodation must also be faxed to the Chief Executive Office - HR Unit, (209) 544-6226.
In the event of an inconclusive drug screen, testing will stop until the specimen has been reviewed by the MRO. Kaiser will contact the Chief Executive Office HR-Unit at (209) 525-6333 or fax at (209) 544-6226.
Other Special Instructions:

For Office Use Only: For additional assistance call: 209-735-4121

Appointment Date/Time:
Authorized By: / Title:
Phone: / Fax:

V:\RM\DM_Unit\Kaiser\Final\Passport\Aging-Vet.doc Form KOJ08 - Revised 07/17/12