Indicate illnesses experienced by you or family (Yes or No)
TB Screen (History and PPD)(Yes or No)
Indicate any illness experienced since last assessment (Yes or No)
I have carefully read and completed this form, and declare that I have no illness or injury, then listed above that will affect my performance while conducting my job’s responsibilities. I am not addicted to any stimulants, drugs, or narcotics, including anti-depressants, or any other substances that may alter my behavior, including alcohol.