Get the free Occ Health Intake Form - Watertown Regional

Occupational Health 123 Hospital Drive, Suite 2004 Watertown, WI 53098 920.262.4253 920.262.4707 fax Authorization Your Company Name: Phone: Please read the following before sending your employee’s):

How to fill out occ health intake form

How to fill out an OCC health intake form:

1. Start by carefully reading through the entire form to understand the information being requested.
2. Enter your personal details accurately, including your full name, date of birth, address, and contact information.
3. Provide any relevant medical history, including previous illnesses, injuries, surgeries, or chronic conditions.
4. Answer questions regarding your current job or occupation, such as the nature of your work, any physical demands, or exposure to hazardous materials.
5. Provide information about your previous employment, including the dates of employment, job responsibilities, and any known workplace hazards.
6. Indicate any specific health concerns or issues you may have that need to be addressed during the examination.
7. If applicable, disclose any medications you are currently taking, including dosage and frequency.
8. Sign and date the form to confirm that the information provided is true and accurate to the best of your knowledge.

Who needs an OCC health intake form:

1. Employees who are starting a new job may need to fill out an OCC health intake form as part of the onboarding process.
2. Current employees may be required to fill out an OCC health intake form periodically to assess their ongoing health and fitness for the job.
3. Individuals undergoing medical assessments or examinations for specific occupational health purposes, such as fitness for specific roles or evaluations for disability claims, may also need to complete an OCC health intake form.

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