Tuberculosis skin test results: testing required per Regulations of the Department of Health.
Significant reaction: if a significant reaction was reported, the primary care provider report must state that the applicant is currently free from tuberculosis disease.
Chest X-ray: attach a copy of the report.
Restrictions: are there any special medical problems or chronic diseases which require restriction of activity?
Accommodations: are there any special equipment or accommodations needed to enable this person to perform their duties?
Employee statement: I understand that any false or misleading statements may cause termination of my employment.
| Question | Answer |
|---|---|
| Form Name | H511.340 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 210 |
| Avg. time to fill out | 35 min |
| Edition | Rev 5/2019 |
| Other names | H511.340, H511340, School Personnel Health Record |
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