US HEALTH WORKS

NEW HIRE

ANNUAL SURVEILANCE

EMPLOYER’S REQUEST FOR OCCUPATIONAL HEALTH SERVICES (# 066149)

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:
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
Department Name: / Area Agency on Aging/Vet Serv. / Department Contact / Bipin Surti
Phone: / (209) 525-4609 / Fax:
Fund/Org: / 1051/0031100 - Area Agency on Aging0100/0032100 - Veterans Services / Email: /

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
US Health Works Scheduling/Special Instructions:
Email all results to Department and to . 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. US Health Works will contact the Chief Executive Office HR-Unit at (209) 525-6333 or fax at (209) 544-6226.
Other Special Instructions:

Complete required medical questionnaire in advance of appointment to save time. Medical questionnaires are available on line. If you do not complete the questionnaire in advance please arrive at your appointment 30 minutes prior to your appointment time.

For Office Use Only: For additional assistance call: 209-575-5801

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

Medical Questionnaire(s):

http://www.ushealthworks.com/Docs/USHW_Employment%20Exam%20Forms%20%20Eng.pdf

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V:\RM\DM_Unit_Shared_Documents\USHealthWorks\Dept Passport\AAVA Passport 2015.docx USHW 2015