Privacy Issues in the Community College Workplace

A PPENDIX C

S AMPLE F ORM : C ONSENT TO P RE -P LACEMENT P HYSICAL E XAMINATION AND R ELEASE OF M EDICAL I NFORMATION

Explanation

The Pre-Placement physical examination is a part of the application process for employment with the Agency. Employment with the [Enter Name] Community College District is contingent upon conducting the below-mentioned medical tests. Hiring decisions may be based on the results of these medical tests. Failure to submit to these tests, absent prior arrangement with the District and the physician performing the physical examination will result in denial of the application for employment.

The following tests are a part of the physical examination*:

 Chemical panel, comprehensive blood count and coronary risk evaluation.

 Chest x-rays (unless chest x-rays have been recently accomplished, the applicant makes the negatives available to the examining physician at the time of the physical examination and the examining physician determines that current x-rays are needed).  Electrocardiogram (for any applicant who the examining physician believes may have evidence of a cardiovascular problem).  For the safety-sensitive positions of ___________, ________, and _________, Drug and alcohol screening urine test. I hereby authorize a qualified representative and/or physician to conduct the above-stated medical tests and above-mentioned physical examination. I understand that the physical examination is a part of the application process for employment with the District and that a hiring decision may be based on the results of the physical examination. I further authorize __________________________ (physician or testing facility) to release to the District all above- mentioned test results conducted as part of the physical examination and other relevant medical information. This authorization shall expire on ______________(date). Authorization

______________________________________________________________________________ Signature of Applicant Date

I understand that I have a right to receive a copy of this authorization on request. By placing my initials in the margin to the right of this clause, I hereby acknowledge that I have received a copy.

Privacy Issues in the Community College Workplace ©2019 (c) Liebert Cassidy Whitmore 181