Employee Medical/Emergency Information Form

 
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  Pursuant to Board Policies: 4112.4/4212.4, all district employees must complete and submit annually an updated Health History and Assurance Statement by September 20th each year. All information shall be confidential. All records shall be secured and maintained separately from staff personnel files. Access to the medical information shall be restricted to the employee, Superintendent, and the school medical examiner. The school nurse may have access only with the employee's consent. Failure to comply shall require the employee to undergo a physical examination by a licensed physician.
   
  HEALTH HISTORY INFORMATION
   
 
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  EMERGENCY CONTACT INFORMATION
   
 
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  EMPLOYEE STATEMENT OF ASSURANCE
   
 
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  Select Date
mm/dd/yyyy
   
  PART II (OPTIONAL)
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
  Select Date
mm/dd/yyyy
   
 
 
 
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