Work Care / Occupational Health Services

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.

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:

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

Additional sheets may be used if needed

WORK ENVIRONMENT WORKSHEET

Candidate Name: Agency: Phone:

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

Work Hours: Works Alone? Yes % of time No

Days Eves Nights

Rotating:Yes No

Extended:Yes No

Explain:

Revised 01/2017Page 1 of 5