Get Employee Medical Information Form

Filling out the Employee Medical Information Form online is a straightforward process that ensures your medical information is properly documented. This guide provides clear instructions to help you navigate through each section of the form efficiently.

Follow the steps to complete your form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by indicating your anticipated status by selecting the appropriate option from the list, such as 'Rotating Resident' or 'Volunteer'.
3. Fill in your personal details including your name (last name, first name, middle initial), birth date, and complete address (street, city, state, zip code). Make sure to double-check for accuracy.
4. Provide your social security number, gender, email address, and telephone number (indicate if it is a cell, home, or work number).
5. Complete the emergency contact information by entering the name, relationship to you, and contact number of your emergency contact.
6. Select your ethnic group from the options provided. This information helps ensure diversity is recognized in the workplace.
7. Indicate whether you are able to perform the essential functions of the position with or without accommodation and detail any requested accommodations.
8. Fill in details about your educational background, including the name of the school, institution, and anticipated graduation date.
9. State the department you will be reporting to and the duration of your stay at the Nassau University Medical Center.
10. List any required rotations separately by providing the department, supervisor, start date, and end date.
11. Document the date of your last physical exam and ensure all related paperwork is submitted to the Employee/Occupational Health Department.
12. Provide information on any foreign languages spoken fluently, professional degrees, and license details if applicable.
13. Fill in your parking information for security purposes, including car make, type, plate number, color, and state.
14. Read the affirmation statement carefully, sign it to confirm that your answers are true and correct, and date your signature.
15. Ensure that any required signatures from departmental representatives or human resources are obtained.
16. Once you have filled out all sections, save your changes, and proceed to download, print, or share the completed form as necessary.

Complete your Employee Medical Information Form online today to ensure all your information is accurately captured and submitted.