US HEALTH WORKS

NEW HIRE

ANNUAL SURVEILLANCE

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:
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: / StanislausCounty
Department Name: / Environmental Resources / Department Contact / Merry MayhewLillie FarriesterHeidi HidalgoMae SongCathy Winchester
Phone: / Fax:
Fund/Org: / 1001 0034110 DER4021 0041100 Fink Rd1001-0034110 Intern / Email: / & & & &

Drug Screen Mandatory For All New Hires

* Select Type of Manager based on duties.

Account Clerk I, II, III
Accountant I, II, III
Accounting Technician
Administrative Clerk I, II, III, IV
Administrative Secretary
Application Specialist I, II, III
Assistant Director
Associate Civil Engineer
Confidential Assistant I, II, III, IV, V
Director of Environmental Resources
Required Examination:
PP1
Clerical Community Aid or Intern
PP1 AND TB and Hep B screening / Environmental Health Specialist I, II, III & Senior
Manager I, II, III, IV *(Office)
Milk & Dairy Inspector I, II, & Supervisor
Resource Mgmt Specialist I, II, III, & Senior
Software Developer/Analyst I, II, III
Staff Services Coordinator, Analyst, Technician
Supervising Account/Admin Clerk I, II
Systems Engineer I, II
Zoning Enforcement Officer & Deputy
Zoning Enforcement Officer (Graffiti Abatement)
Optional Services:
Ergonomic Evaluation by PT
* Select Type of Manager based on duties.
Environmental Technician
Hazardous Materials Specialist I, II, III
Manager I, II, III, IV *
Senior Hazardous Materials Specialist I, II, III
Required Examination:
HAZ1, PPD, Flu Shot, Audiogram,
Spirometry,CBC/diff, Chem 7 Panel,
Venipuncture(8 hours fasting required)
Optional Service:
Chest X-ray, PA for +PPD
Ergonomic Screening or FCE by PT
DMV/Form
EKG Stress Treadmill(4 hours fasting required)
HazMat – Annual/Periodic (NO DRUG) / Environmental Technician
Landfill Equipment Operator I, II, III
Landfill Lead Worker
Landfill Maintenance Engineer
Manager I, II, III, IV*
Required Examination:
PP2, Audiogram
Optional Service:
Ergonomic Screening or FCE by PT
DMV/Form
* Select Type of Manager based on duties.
US Health Works Scheduling/Special Instructions:
Email all results to Department Contact atas noted on page 1 and to the Disability Management Unit at . 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):

Respirator_Medical_Evaluation_Questionnaire.pdf

(commercial driver)

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