Prime EME

Employee Information

This form is used as a part of your occupational fitness evaluation. No medical evaluation or treatment is intended or being offered. Truthfulness is critical. Any false information may be subject to your employer's disciplinary action, including job termination.

First Name: *

Last Name: *

Date Of Birth:*

Social Security Number:*

Contact Phone Number:*

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Confirmation

I have completed this form honestly and to the best of my knowledge. I understand that providing false information or omitting pertinent information could result in loss of my workers compensation benefits should I become injured on the job.

E-Signature *

Prime Occupational Medicine | PH - LA OWCA Second Injury Board Knowledge Questionnaire

Employee Information

Confirmation