Employer S Request for Occupational Health Services

Please complete all information and check appropriate job title. KAISER PERMANENTE Fax appointment request to: Modesto KOJ (209) 735-4109 Kaiser-On-the-Job

EMPLOYER’S REQUEST FOR OCCUPATIONAL HEALTH SERVICES

PRE-EMPLOYMENT INSTRUCTIONS: TAKE THIS FORM AND A PICTURE I.D. TO THE CLINIC LOCATION INDICATED WITHIN 48 HOURS FROM THE DATE AND TIME LISTED BELOW (FAILURE TO DO SO ELIMINATES YOU FROM FURTHER CONSIDERATION FOR THE POSITION):

CANDIDATE/EMPLOYEE INFORMATION:

DATE/TIME PASSPORT ISSUED: KP MEMBER: Y / N

NAME: SEX: Male / Female (First) (Middle Initial) (Last) (Maiden if applicable) (circle one) ADDRESS: PHONE #

SOCIAL SECURITY NUMBER CDL/PHOTO I.D. NUMBER I.D. TYPE D.O.B. (LAST SIX DIGITS ONLY)

Appointment Date: Appointment Time: Company Name: Stanislaus County Kaiser Medical Record No#: Department Name: SHERIFF’S OFFICE Department Contact Phone: Fax: Fund/Org: 0100/28107 Other:

DRUG SCREEN MANDATORY FOR ALL NEW HIRES

Account Clerk I, II, III Security Officer Accountant I, II, III Software Developer/Analyst I, II, III & Senior Accounting Technician Staff Services Coordinator, Analyst, Technician Administrative Clerk I, II, III, IV Stock/Delivery Clerk I, II Administrative Secretary Storekeeper I, II Application Specialist I, II, III Supervising Account/Admin Clerk I, II Clerical Community Aide Supervising Legal Clerk I, II Clerical Division Supervisor Supervising Public Administrator Confidential Assistant I, II, III, IV, V Systems Engineer & Senior Data Processor & Senior Systems Technician Legal Clerk I, II, III, IV Manager I, II, III, IV (non-sworn) Optional Services: Required Examination: Ergonomic Evaluation by PT PP1

D:\Docs\2018-04-28\08350ff847a3af39a11f62721470b918.doc Form KOJ08 - Revised 07/17/2012 Bomb Squad SCUBA Community Service Officer Captain Sergeant Cook Series Custodial Lieutenant Sergeant Custodial Crime Analyst Deputy Sheriff Sheriff Crime Analyst Technician Deputy Sheriff Custodial SWAT Custodial Cook Lieutenant Under Sheriff Deputy Coroner (non-sworn) Manager (sworn) First/Second Cook Food Service Worker Required Examination: Forensic Pathologist POST, PPD, Audiogram, Hep B & Hep C, Supervising Custodial Cook Flu Shot (vision uncorrected limit: 20/100) Required Examination: Optional Service: PP3, PPD, Flu Shot

CBC/diff Optional Service: Chem panel 20 Chest X-Ray, PA for +PPD Audiogram EKG Chest X-Ray, PA for +PPD Spirometry Ergonomic Eval by PT TdaP (Tetanus, Diphtheria, Pertussis) Hep B Vaccine Treadmill (4 hour fasting required) Measles, Mumps, Rubella, (MMR) vaccine Pneumococcal Vaccine TdaP (Tetanus, Diphtheria, Pertussis) Titers: (list here) Varicella (Varivax) Vaccine

KAISER SCHEDULING/SPECIAL INSTRUCTIONS: Fax all results to Department Contact at - and to the Disability Management Unit at (209)525-5779. Any notice of unqualified, or qualified with accommodation must also be faxed to the Chief Executive Office - HR Unit, (209) 544-6226. In the event of an inconclusive drug screen, testing will stop until the specimen has been reviewed by the MRO. Kaiser will contact the Chief Executive Office HR-Unit at (209) 525-6333 or fax at (209) 544-6226.

Other Special Instructions:

DEDICATED OCCUPATIONAL HEALTH CENTER Modesto Medical Offices 4601 Dale Road, 4th Floor Modesto, CA 95356 Hours: M-F (209) 735-4121 8:30am-5:00pm

For Office Use Only: For additional assistance call: 209-735-4121 Appointment Date/Time: Authorized By: Title: Phone: Fax:

D:\Docs\2018-04-28\08350ff847a3af39a11f62721470b918.doc Form KOJ08 - Revised 07/17/2012