Post-Offer Medical Questionnaire

In compliance with the Americans with Disabilities Act of 1990 (ADA) you have received a conditional offer of employment. The answers to this medical questionnaire will be kept confidential as required by the ADA and HIPAA. The job offer, which you have received, is conditioned upon the satisfactory completion and review of this post-offer medical questionnaire, any required medical examination or follow up and job assignment availability. The purpose of this questionnaire is to determine whether you currently have the physical qualifications necessary to perform the essential job functions for security services; to determine whether and what accommodations may be necessary; and to determine whether you can perform the essential job tasks without posing a significant/direct threat to the health and safety of yourself and/or others.

Personal Information:

Medical Questions:

Answer each of the following questions. If answered "yes", please explain in the box provided.

  • Have you ever been admitted to the hospital as a patient?
  • Have you ever been injured on the job?
  • Have you ever had to file a Worker's Compensation Claim?
  • Have you had a major illness in the past five (5) years?
  • Do you have a condition which would require frequent absence from work?
  • Do you have a disability that would require a reasonable accommodation in order to perform the essential job functions?
  • Have you ever lost consciousness, fainted or had a seizure? If yes, please give the most recent date.
  • Have you ever suffered heat exhaustion, heat stroke or hypothermia?
  • Have you ever been diagnosed with any heart conditions, including but not limited to, Hypertension, Peripheral vascular abnormality, Congenital Heart Disease, Valvular Heart Disease, Coronary Heart Disease, ECG Abnormalities, Angina, Congestive Heart Failure, Cardiomyopathy, Pericarditis, Endocarditis or Myocarditis?
  • Have you ever been diagnosed with a nervous system disorder, including but not limited to, Seizure Disorder, Cerebral Palsy, Movement Disorder (to include Parkinson's), Cerebral Aneurysms, Syncope, Progressive Neurological Diseases (to include Multiple Sclerosis and Huntington's Chorea), Peripheral Nerve Disorder (to include Polyneuritis, Mononeuritis, and Neurofibromatosis), Narcolepsy, Cerebral Vascular Accident or Central Nervous System Infections?
  • Have you ever been counseled for or treated for any psychological or emotional conditions or institutionalized for such a problem?
  • Have you ever been diagnosed with behavioral disorder, including but not limited to, Attention Deficit Disorder (ADD) or Attention Deficit Hyper Activity Disorder (ADHD)?
  • Have you ever been diagnosed with a personality disorder, including but not limited to, schizod, paranoid, schizotypal, antisocial, borderline, narcissistic, avoidant, dependent, or obsessive-compulsive disorders?
  • Have you ever been diagnosed with mood disorder, including but not limited to, major depression, bipolar disorder or anxiety?
  • Have you ever tried to harm yourself?
  • Have you ever been diagnosed with post traumatic stress disorder (PTSD) or suffered a traumatic brain injury (TBI)?
  • Have you been diagnosed with any form of psychosis?
  • Have you undergone rehabilitative treatment for injuries, illness, or additions?
  • Are you currently taking any prescription medications?
  • Have you ever used Marijuana/THC? If yes, when was the last time?
  • Have you ever used Hashish, Heroin, Quaaludes, Downers, Speed/Meth, LSD/Acid, Mescaline, Peyote, Mushrooms, PCP/angel dust, Ecstasy, Steroids, Illy, Nitrous Oxide, Rush or any other illegal narcotic? If yes, when was the last time?

By having completed the post-offer medical questionnaire and clicking submit, you hereby affirm that Raven Security has made an offer of employment and you have reviewed the essential job functions detailed in the position you have applied for. You hereby affirm that the questions in this post-offer medical questionnaire have not been asked of you by our company until after you accepted a conditional offer of employment. The information provided in this questionnaire will be kept confidential.

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