Exhibit_H_Pre_Employment_Physical_-_Healthy4Life_new_logo_updated_7.22.pdf

CITY OF ST. CLOUD

HUMAN RESOURCES DEPARTMENT

1300 9th Street * St. Cloud, Florida 34769 Phone: 407-957-7223 Fax: 407-957-7273

To: Healthy 4 Life Employee Health Care Center

2950 Lakeshore Boulevard, St. Cloud, FL 34769 * Phone: 407-957-7218 *Fax: 407-957-7210 Pick Up Date: Pick Up Time: Job Title*:

Expire Date:

Expire Time:

*See attached job description

This letter shall serve as authorization to perform the following services for:

New Hire Candidate Name: ___________________________________________________

Candidate Phone Number: ( __)_____________________ S.S. #: _____ - _____ - _____

Pre-Employment Drug Test ONLY Includes 10 Panel Non- DOT Drug Screen

General Employee Pre-Employment Physical Includes Physical, Vision Screening, Drug Screen, Audiometric Test and Low Back Assessment (#lbs: ______*)

DOT Pre-Employment Physical Includes Physical, DOT Drug Screen, Vision Screening, Audiometric Test and Low Back Assessment (#lbs:

______*) and completion of DOT Medical Evaluation/Certificate

Police Officer Pre-Employment Physical Includes Physical, 10 Panel Non- DOT Drug Screen, Vision Screening, Audiometric Test, Low back Assessment (#lbs: ______*), EKG, PPD, PFT, Hepatitis B Titer, Hepatitis C Titer, Lead, ZPP (if necessary), and completion of FDLE Assessment

Fire Fighter Pre-Employment Physical Includes Physical, 10 Panel Non- DOT Drug Screen, Vision Screening, Audiometric Test, Low Back Assessment (#lbs: ______*), EKG, PPD, PFT, Hepatitis B Titer, Hepatitis C Titer and Nicotine Metabolite Screen

*If low back assessment is 50lbs or greater, please complete the enclosed Low Back Assessment form.

NOTICE TO NEW-HIRE CANDIDATES

If physical/drug screen is not done within the above timeframe, we will rescind your contingent offer of employment. All persons are to bring a photo ID. Persons under 18 years of age must bring parent or guardian.

Please DO NOT BRING CHILDREN to the Healthy 4 Life Employee Health Care Center unless another adult is with you to supervise them while you are being examined.

New Hire Candidate Acknowledgment Date Received

Company Authorization

This letter has been issued and authorized by the following individual:

Lillian Rosario, HR Specialist, 407-957-8435 Wanda Espinal, HR Specialist, 407-957-8452

Signature Date

INSTRUCTIONS FOR COMPLETING

PRE-EMPLOYMENT DRUG SCREEN AND PHYSICAL:

1. Job description may be provided upon request for job’s physical requirements.

2. Complete attached physical and drug screen forms, circle satisfactory or unsatisfactory on physical, sign and email or fax all copies of forms and tests to: Lillian Rosario or Wanda Espinal, City of St. Cloud at.

3. If you have any questions, please call (407) 957-8435 or (407) 957- 8452.

Thank you.

1300 9th Street * St. Cloud, Florida 34769 Phone: 407-957-7223 Fax: 407-957-7273

PRE-EMPLOYMENT PHYSICAL EXAMINATION EVALUATION

FOR CITY OF ST. CLOUD

PHONE: (407) 957-7223 - OR - (407) 957-8420 - FAX – 407-957-7273

Applicant’s Name: ________________________________________________ Date: ____________

TO BE FILLED OUT BY APPLICANT

OCCUPATIONAL HEALTH/MEDICAL HISTORY

Please check in the space if you ever had, or if you now have:

Asthma Hay Fever Amputations Arthritis Sinus Problems Gout Frequent Colds Cancer/Tumors High Blood Pressure Ear infections Hormone Problems Vision/Hearing Problems Diphtheria Rheumatic Fever Whooping Cough Chicken Pox Prostate Problems Hernia Measles/Mumps Pneumonia/Lung Disease Syphilis Ulcers Head Injuries Spinal Injuries Thyroid Problems Seizures/Convulsions Diabetes (sugar) Back Strains/Injuries Kidney Problems/Stones Dizziness or Fainting Spells Frequent Headaches/Migraines Carpal Tunnel or Neuropathies Nervous/Mental/Emotional Problems Heart Problems (chest pain, palpitations) Frequent Urinary Infections Received Blood or Blood Products Broken Bones Date of Last Tetanus Shot: ___________ DeQuervuin’s Disease

Do you wear? How Long?

___ Hearing Aid L R _________ ___ Glasses/Contacts _________ ___ Prosthetics (artificial limbs) _________

Are you allergic to any medications: ___Yes ___No If so, give details: _________________________________ Current Medications: ______________________________

1. Average hours of sleep each night? ___ Trouble getting to sleep or staying asleep? __Yes __No

2. How often do you eat a good breakfast? ___ Almost always ___Sometimes ___Rarely or never

3. How often do you eat between your regular meals (including all calorie containing beverages)?

___ Rarely or never ___Occasionally ___Almost every day

4. How often do you get regular vigorous exercise?

___ Often (3 or more times/week) ___Occasionally ___Seldom or never

5. When you drink wine, beer or liquor, how many drinks do you usually have at one sitting?

___ Never drink ___1-2 drinks ___3-4 drinks ___5 or more drinks

6. What is your smoking status? ___ Never Smoked ___ Quit smoking, when? ___________________________ __ Smoke a pipe/cigar only, how many per day?___ ___ Smoke cigarettes, how many per day? ____

7. Do you use chewing tobacco? __Yes __No Do you use snuff? __Yes __No

8. Are you taking prescription medications? Over the counter pills/supplements, or inhaler? __Yes __No If yes, please list: _________________________________________________________________________

9. Do you use drugs, or have you ever used (marijuana, cocaine, heroin, etc)? __Yes __No Amount: _________ Length of time used? ________________

10. Surgical History: Have you had an operation? __Yes __No If so, for what, where, when (date): ______________________________________________________________ Doctor’s Name: _____________________________________________________________________________

11. Have you ever been injured at work? __ Yes __ No If so, give details: ________________________________

12. Are there any limitations on your ability to work? __Yes __No

13. Have you ever been refused employment or insurance? __Yes __No

APPLICANT’S DECLARATION: I certify that all statements and answers provided by me on this form are complete and true to the best of my knowledge, and that any falsifications may be cause for discharge. I further authorize the release of any information from the past or present medical records.

Applicant’s Signature (or guardian) Date

PRE-EMPLOYMENT PHYSICAL EXAMINATION EVALUATION

PHONE: (407) 957-7223 – OR – (407) 957-8420 - FAX – 407-957-7273

Applicant’s Name: ______________________________ Age: ________ DOB: _____/____/____ Sex: _______

Applicant’s Address: __________________________________________ Applicant’s Phone: (_____) ___________

Applicant’s Primary Care Physician: _____________________________ Physician’s Phone: (_____) ___________

TO BE FILLED OUT BY PROVIDER

Position Applying For: _________________________________________ Date: ___________ General Appearance & Development: _______ Good _______ Fair _______ Poor

Vital Signs: T______ P______ R______ B/P______ Height: ______ft. ______in. Weight: ______ lbs.

Vision: With glasses 20/______OD 20/______OS 20/______OU Hearing: ______AD _____AS

Without glasses 20/_____OD 20/_____OS 20/____OU Color Vision: ____Normal ____Abnormal

ABNORMAL NORMAL

HEAD: shape, deformity EYES: pupils, fundi, EOM NOSE: airway, DNS, turbinates SINUSES: tenderness MOUTH: tongue TEETH: dentures, partial, upper, lower THROAT: tonsils NECK: ROM, JVD, bruits, adenopathy THYROID: tenderness, masses, enlargement CHEST: excursion, expansion, tenderness, deformity LUNGS: breath sounds HEART: murmurs, PMI, rhythm, gallop ABDOMEN: masses, tenderness, bowel sounds, organomegaly HERNIA: ventral, inguinal, umbilical EXTREMITIES: deformity, ROM, cyanosis, clubbing, edema VASCULAR: distal pulses, varicose veins, bruits SKIN: scars, infections, disfigurements, tattoos SPINE: shape, curvature, ROM, tenderness, surgery MENTAL/NEURO: CN, Rhomberg, EIN, gait, muscle strength LYMPH: adenopathy, edema

URINALYSIS:

Glucose Protein Blood Ketones Spar pH Nitrate

POLICE/FIRE ONLY

EKG

TB Test Pulmonary Function Baseline Lead Test Hepatitis B and C

OTHER

PRE-EMPLOYMENT PHYSICAL EXAMINATION EVALUATION

PHONE: (407) 957-7223 - OR - (407) 957-7220 - FAX – 407-957-7273

Applicant’s Name: ________________________________________________ Date: ____________

TO BE FILLED OUT BY PROVIDER

Lifting Capacity by ISTU

Max repetitive 4/min ________ lbs Max occasional 2/hr ________ lbs

Impairment ____________%

Drug Screen

Done: _________ Not Done: ________

Baseline Lead Test (Police Only)

Results: _______________

Assessment (based upon review of attached job description):

___________ Recommended for work, no restrictions.

___________ Recommended for work, with restrictions (see attached work duty status form)

___________ Not recommended for work.

Ginger Martinez, PA-C Date