WORK CARE / OCCUPATIONAL HEALTH SERVICES

POST-OFFER PHYSICAL REQUEST COVER SHEET

Use of form in lieu of portal. The document must be completed and received by WorkCare before the candidate is scheduled for the post-offer physical exam.

Neither WorkCare nor Occupational Health Services is responsible for verifying the content of this document. The Agency representative who prepares and signs this document is verifying accuracy and completeness.

Candidate Name: / Candidate Location (City/State):
Last four digits of Social Security: / Date of Birth:
Candidate Phone: / Alternate Phone:
Candidate Email: / Alternate Email:
Job Class Code Description: / Job Class Code: / Position #:
Agency: / Agency Address:
OPTIONAL: Please provide the candidate’s dates/times of availability for their exam.
Note that this exam will take up to about 2-3 hours.
Exams are scheduled Monday through Friday, 8AM – 5PM.
List 3 choices – Include dates and time range for each day
Preferred/Closest Clinic (refer to Clinic Listing on next page):
Choice1: Choice 2: Choice 3:
Mark if an out of stateclinic required - List zip code
Date and Time Range #1:, Choice 2: , Choice 3: ,

Prepared by:Preparer’s Position Title:

Contact (if different than Preparer):

Email Address: Phone: Fax:

PLEASE CHECK OFF THE FOLLOWING MANDATORY INFORMATION:

Lifting/Carrying: pounds (note: enter max number of lbs. candidate will lift/carry)

Type: Floor/Waist Floor/Shoulder Floor/Above Shoulder Floor/Overhead

Other If lift is > floor to overhead, list what person is lifting:

Pushing/Pulling: pounds

Type: Using wheels Over smooth surfaces Over rough surfaces Up/down inclines

Other:

Toxic Substances– Exposures? Yes No Explain nature of exposure:

CDL Required:Yes No AZ POST Exam/Report Required:Yes No

(Peace Officers)

Special Instructions:

Forward the completed cover sheet and the corresponding Work Environment Worksheets, PDQs or Physical Job demands to: WorkCare.
Email to FAX to (714) 922-1011

If you have any questions or need additional help, contact State Risk Management at 602-542-2175, or

WorkCare at 1-800-455-6155 x2219,

CLINIC LISTING

The following list is sorted by Zip Code

Clinic Name / Address / City / Zip
Good Samaritan-Phx / 1300 N 12th Street, #520 / Phoenix / 85006
MBI-W Osborn / 3501 West Osborn Road / Phoenix / 85017
Concentra-Phx-Black Canyon / 12808 North Black Canyon Highway / Phoenix / 85029
Concentra-Phx-Sky Harbor / 1818 E. Sky Harbor Circle North, Ste 150 / Phoenix / 85034
US Healthworks-SWPhx / 2010 N. 75TH AVENUE / Phoenix / 85035
Banner Estrella-Phx / 9305 W. Thomas Road, Ste 235 / Phoenix / 85037
MBI-Broadway / 4100 E. Broadway / Phoenix / 85040
Concentra-Phx-Buckeye / 5340 W. Buckeye Rd., Suite 3 / Phoenix / 85043
Concentra-Mesa-Southern / 1710 W. Southern / Mesa / 85202
Desert Samaritan / 2225 W Southern / Mesa / 85202
Concentra-Mesa-Val Vista / 1959 South Val Vista Dr, Ste106 / Mesa / 85204
MBI-Casa Grande / 177 W Cottonwood Lane / Casa Grande / 85222
Banner Gateway-Gilbert / 1920 N. Higley Rd. Suite 108 / Gilbert / 85234
US Healthworks-Scottsdale / 10335 N. Scottsdale Road / Scottsdale / 85253
US Healthworks-Tempe / 1492 SOUTH MILL AVENUE / Tempe / 85281
Concentra-Tempe / 950 W. Southern / Tempe / 85282
Thunderbird Samaritan / 5601 W. Eugie Ave., Suite 213 / Glendale / 85304
Pinnacle Health Care / 4343 East 31st Place / Yuma / 85365
Concentra-Peoria / 14155 N 83 Ave, Bldg.8, Ste 148 / Peoria / 85381
Diversified Solutions-Globe / 1400 South Street / Globe / 85501
Gila Health-Morenci / 401 Burro Aly / Morenci / 85540
Copper Queen Community Hospital / 101 E Cole Avenue / Bisbee / 85603
Concentra-Tucson-Ruthrauff / 2005 W. Ruthrauff #111 / Tucson / 85705
Concentra-Tucson-Broadway / 7119 E. Broadway Blvd / Tucson / 85710
WellAmerica / 1951 N Wilmot, Bld 1 , Ste 3A / Tucson / 85712
Concentra-Tucson-S. Park / 4600 S. Park, Ste 5 / Tucson / 85714
Summit Healthcare-Show Low / 2200 E. Show Low Lake Rd / Show Low / 85901
Concentra-Flagstaff / 1110 E. Route 66 Suite 100 / Flagstaff / 86001
Chino Valley Medical / 474 N. Highway 89 / Chino Valley / 86323
Kingman Regional Medical / 1739 Beverly Ave., Suite 118 / Kingman / 86409
Note: If your candidate is out of state then note the zip code(s) closest to their requested location
ESSENTIAL FUNCTIONS
Please number each Essential Function, 1, 2, 3 etc...
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Additional sheets may be used if needed

WORK ENVIRONMENT WORKSHEET

Candidate Name: Agency: Phone:

Use these codes: (C =continuously (>66%); F = frequently (34-66%); O = occasionally (10-33%) or R = rarely (<10%) Physical Demands / Frequency / Essential Function(s)
(list EF numbers from pg.2)
Balancing (Provide details)
Climbing (Provide details)
Crawling (Provide details)
Driving (State vehicle or own vehicle for State business)
Fine Dexterity
Foot Controls
Hearing
Kneeling/Crouching/Bending
Manual Dexterity
Lifting/Carrying pounds
Floor to waist Floor to chest Floor to shoulder Floor to overhead Other:
Pushing/Pulling pounds
Using wheels Over rough terrain
Up/down inclines Other:
Reaching
Sitting
Standing
Talking
Twisting
Upper Extremity Repetitive Motion
Vision
Walking/Running
Short distances
Long distances
Other (describe)

Providing as much information as possible about the work demands for your job candidate will help us do the best evaluation to ensure his/her ability to safely perform the essential functions of the job.

WORK ENVIRONMENT WORKSHEET

Non-Physical Demands / Frequency / Essential Function(s)
(list EF numbers from pg. 2)
Analysis/Reasoning
Communication Skills
(distinguish from "talking" if additional requirement to simultaneously mentally analyze/or reason and verbally express)
Math/Mental Computation
Reading
Sustained Mental Activity:
(example: auditing, grant writing, composing reports, problem solving)
Writing
Other (describe)
Environmental Demands / Frequency / Essential Function(s)
(list EF numbers from pg. 2)
Dust
Frequent Task Changes
High Volume Public Contact
Loud Noises
Physical Abuse/Physical Danger
Tedious/Exacting Work
Temperature Extremes
Toxic Substances
(list and provide MSDS for each substance)

Work Hours: Works Alone? Yes % of time No

Days Eves Nights

Rotating:Yes No

Extended:Yes No

Explain:

Revised 01/2017Page 1 of 5