Pre-placement Candidate's Name* First Middle Initial Last Suffix Candidate's Last 4 Digits of SSN* Job Applying For* Company Applying To* Candidates Email Address* Candidate's Phone Number* Candidates health questionnaire was reviewed in conjunction with corresponding job description. The information obtained from the medical screening questionnaire was used to make the following determination:* QUALIFIED to perform the primary job functions and tasks required for this position. Candidate proceed to the next phase of medical screening, as directed by Human Resources. NO DETERMINATION: Please collect additional information in order to reach a determination. NOT QUALIFIED to perform the primary job functions and tasks required for this position. Candidate may re-apply for a job opportunity in 30 days. Medical Provider for remote locations will call candidate’s number listed on Questionnaire.Reviewer to initial when call completed. If candidate has not received a call and explanation in 24 hours call 865-558-3038We certify that the assessment accurately reflects our informed professional opinion regarding the information presented concerning the above named candidates ability to perform the tasks as indicated in the job description stated above.Additional InformationSignature of Reviewing Healthcare Provider* Date of Assessment* MM slash DD slash YYYY Recipient's Email 1 Recipient's Email 2 Also send this Assessment to: hr@mersino.com hthompson@ohswest.com rflowers@ohswest.com asugantharaj@ohswest.com jmullholand@ohswest.com wblankenship@ohswest.com
