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EMPLOYEE STATEMENT OF HEALTH Short Form Small Group 2550 10421 South Jordan Gateway, Suite 400 South Jordan, Utah 84095 Important: Please complete this statement for all family members, whether they

How to fill out employee statement of health

How to fill out an employee statement of health:

1. Begin by labeling the document with the employee's personal information, such as their full name, date of birth, and employee identification number.
2. Proceed to provide details related to the employee's current health status. Include questions regarding any pre-existing medical conditions, current medications being taken, and any known allergies.
3. Include sections for the employee to disclose their medical history, including any past surgeries, hospitalizations, or significant illnesses. It is crucial to request specific dates and details for accuracy.
4. Inquire about the employee's lifestyle habits, such as smoking, alcohol consumption, and exercise routines. This information is important in assessing health risks and potential lifestyle modifications.
5. Ensure there is a section for the employee to indicate any immediate family members with serious medical conditions or a history of hereditary diseases. This assists in determining possible genetic predispositions.
6. Prompt the employee to disclose any recent injuries or accidents. This information is crucial for workplace safety and may impact the employee's ability to perform certain tasks.
7. Include an area for the employee to list their primary healthcare provider's contact information. This facilitates open communication and allows for verification of medical information.
8. Conclude the employee statement of health with a declaration, affirming that the provided information is accurate and complete to the best of the employee's knowledge.

Who needs an employee statement of health?

1. Employers often require a statement of health when hiring new employees or promoting existing ones to ensure that they can perform their job duties safely and effectively.
2. Insurance companies may request an employee statement of health for underwriting policies or determining coverage limits. This helps assess the potential risks associated with providing insurance coverage.
3. Occupational health and safety regulatory bodies may require certain industries, such as those involving hazardous materials or physically demanding tasks, to obtain employee statements of health to ensure compliance with safety regulations.

Thus, the employee statement of health serves as a vital document for employers, insurance companies, and regulatory bodies to assess an individual's health status and potential risks.

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