Std 610 Form PDF Details

Navigating the labyrinth of employment prerequisites can often lead to encountering various forms and requirements, especially for those seeking positions within state service. Among these, the State of California - Department of Human Resources Confidential Medical Document, known as the Std 610 form, serves as a critical piece in ensuring the suitability of candidates for their roles, in alignment with state law and the Americans with Disabilities Act. This four-page document is intricately designed to collect comprehensive health-related information from applicants only after a job offer has been extended, emphasizing the state’s commitment to consider health conditions in relation to job responsibilities without breaching privacy or discrimination guidelines. The first half of the form demands candid responses from the applicant regarding a vast array of health questions, while the latter half is reserved for a detailed physician’s report. This not only facilitates a well-rounded evaluation of an applicant's medical fitness but also underlines the importance of safety and accommodation in the workplace. Through sections that require disclosure of conditions that could potentially affect job performance, to the physician’s objective remarks and a review by the California Department of Human Resources' medical officer, the Std 610 form embodies the procedural integrity and attentiveness required in the state’s hiring process. It ensures that the hiring agencies are well-informed of the medical readiness of their prospective employees, underscoring a proactive approach to workplace health and safety management.

QuestionAnswer
Form NameStd 610 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesstd610, how to get form std610 completed, std 610 form, ca questionnaire template

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STATE OF CALIFORNIA − DEPARTMENT OF

 

 

 

 

 

 

 

HUMAN RESOURCES

 

CONFIDENTIAL MEDICAL DOCUMENT

HEALTH QUESTIONNAIRE

 

 

 

 

 

 

 

 

 

(And Physician’s Report)

STATE LAW AND THE AMERICANS WITH

 

STD. 610 (REV 8/2017) (Page 1 of 4)

 

DISABILITIES ACT REQUIRE APPLICANTS TO FILL IN

 

 

 

 

QUESTIONS ON PAGES 1 AND 2 OF THIS FORM

 

 

DATE JOB OFFER MADE

 

ONLY AFTER A JOB OFFER HAS BEEN MADE

 

 

 

 

 

 

 

 

 

 

THIS AREA TO BE COMPLETED BY HIRING AGENCY — COMPLETED QUESTIONNAIRE TO BE RETURNED TO HIRING AGENCY

APPLICANT NAME (Last)

(First)

(Middle)

HIRING AGENCY NAME

APPLICANT ADDRESS (Number and Street)

(City)

(State)

(Zip Code)

AGENCY ADDRESS

CLASS TITLE OF VACANCY

POSITION NUMBER OF VACANCY

HIRING MANAGER

PHONE NUMBER

APPOINTMENT TYPE

 

 

 

PERMANENT

TAU

LIMITED TERM

PEACE OFFICER

REINSTATEMENT

(if reinstatement, enter dates of previous State Employment.)

 

 

 

 

DESIRED APPOINTMENT DATE

CERTIFICATION NUMBER

 

 

CURRENT OCCUPATION

THIS AREA TO BE COMPLETED BY THE APPLICANT ONLY AFTER A JOB OFFER HAS BEEN MADE

DO NOT LEAVE YOUR PRESENT EMPLOYMENT TO ACCEPT A POSITION IN STATE SERVICE UNTIL YOU HAVE BEEN

SPECIFICALLY NOTIFIED TO REPORT FOR WORK. MEDICAL CLEARANCE IS REQUIRED PRIOR TO EMPLOYMENT IN STATE SERVICE.

Your answers to the following questions will be evaluated in conjunction with the essential functions of the desired position.

“YES” answers to questions 1 - 43 below must be explained in the space provided on the back of this form.

BIRTHDATE

MALE

FEMALE

EMAIL

PHONE NUMBER

For questions 1 - 43, have you ever had or do you have the following:

ITEM

YES NO

 

 

 

 

1.Lung or respiratory trouble, including bronchitis, tuberculosis, or asthma

2. Residuals of poliomyelitis

3. Hepatitis, jaundice, or other liver ailments

4. Cancer, malignant tumor, or cysts

5. Diabetes or sugar in urine

6. Pernicious anemia, leukemia, or other blood disorder or ailment

7. Mental illness

8. Any disorder of the nervous system

9. Seizure disorder or loss of consciousness

10. Severe headaches or migraine

11. Heart trouble--including circulatory disease

12. Rheumatic fever

13.Any defect of bones or joints, including amputations, dislocations, or broken bones

14. Rheumatism, arthritis, or bursitis

15. Back pain or back injury

16. Head injury

17. Any problems with hips, knees, ankles, or feet

18. Any problems with hands, elbows, or shoulders

19. Fainting spells or dizziness

20. Skin rash from work

21. Allergies

22. Sensitivity to dust or smoke

23. High or low blood pressure

24. Varicose veins

25. Stomach or duodenal ulcer or other bowel problem

ITEM

YES NO

 

 

 

 

26. Rupture or hernia

27. Gall bladder trouble

28. Kidney or bladder trouble

29. Shortness of breath

30. Any speech impairment

31. History of addiction to drugs or alcohol

32. Do you wear or have you ever worn glasses?

33. Do you or have you ever worn contact lenses?

34. Have you had any eye injury, surgery, or disease?

35. Are you blind in one eye?

36. Are you blind in both eyes?

37.Do you wear hearing aid or have you had at any time a problem with your hearing?

38.Do you have any existing temporary medical condition such as

broken bones, recovery from surgery, pregnancy, etc.?

If yes, list condition and anticipated date of recovery on Page 2.

39.Are you at present under a doctor's care for any condition? Give reason and doctor's full name and address

40.Are you taking any medication now or in the last 12 months? If yes, what?

41.Have you ever been hospitalized?

If yes, list reason and date of hospitalization.

42.a. Have you had an illness or injury which caused you to lose time from work?

b.Does this illness or injury continue to limit your ability to perform certain types of work?

43.Have you ever had any other illness, injury or physical

condition not named above (exclude minor problems such as colds, flu, etc.)?

STATE OF CALIFORNIA − DEPARTMENT OF HUMAN RESOURCES

HEALTH QUESTIONNAIRE

CONFIDENTIAL MEDICAL DOCUMENT

(And Physician’s Report)

STD. 610 (REV 8/2017) (Page 2 of 4)

STATE LAW AND THE AMERICANS WITH

DISABILITIES ACT REQUIRE APPLICANTS TO FILL IN QUESTIONS ON PAGES 1 AND 2 OF THIS FORM

ONLY AFTER A JOB OFFER HAS BEEN MADE

APPLICANT NAME (Last)

(First)

(Middle)

HIRING AGENCY NAME

Please write your own account and your own evaluation of all items to which you have answered “YES” to the prior questions.

Include DATE OF ONSET, YOUR PRESENT CONDITION AS YOU EVALUATE IT and what accommodations to your limitations, if any, you feel you may require to perform satisfactorily the duties of the position for which you are applying without endangering the health and safety of yourself or others. Return this completed form to the hiring agency unless advised otherwise by the hiring agency. Follow their instructions for submission.

Item # Explanation of “YES” Items

Healthcare Provider and Contact Information

CERTIFICATION: I certify that I have provided true and complete information concerning my fitness. (Any misrepresentation or material omission may be cause for dismissal.)

APPLICANT’S SIGNATURE

DATE SIGNED

PHONE NUMBER

EXAMINING PHYSICIAN'S COMMENTS:

PHYSICIAN'S SIGNATURE (MD or DO only)

DATE SIGNED

DO NOT WRITE BELOW THIS LINE - DELEGATED AUTHORITY OR CALIFORNIA DEPARTMENT OF HUMAN RESOURCES OFFICER ONLY

REVIEWER

APPROVED

DISAPPROVED

SUBJECT TO PROPER PLACEMENT

CalHR's MEDICAL OFFICER'S SIGNATURE

DATE SIGNED

CalHR's MEDICAL OFFICER'S NAME (Typed or Printed)

STATE OF CALIFORNIA − DEPARTMENT OF HUMAN RESOURCES

HEALTH QUESTIONNAIRE

(And Physician’s Report)

CONFIDENTIAL MEDICAL DOCUMENT

STD. 610 (REV 8/2017) (Page 3 of 4)

(To be completed by a licensed physician and surgeon only after a job offer has been made)

TO THE PHYSICIAN: The attached Health Questionnaire must be completed and submitted to you by the person whose name appears below. It is intended to assist you in conducting the examination. You are requested to complete the medical examination report.

The Hiring Agency is responsible for payment of the fee. See page 4 for instructions.

ALL ITEMS BELOW ARE MANDATORY--COMPLETED REPORT SHOULD BE RETURNED TO HIRING AGENCY

APPLICANT NAME (Last)

(First)

(Middle)

HIRING AGENCY NAME

 

 

 

 

DOCTOR: Write comments on any positive or negative findings for evaluation of applicant.

JOB CLASSIFICATION/TITLE

(If more space is needed, use reverse of this form and/or a separate sheet of paper.)

 

Examine color vision only when required in Minimum Qualifications.

 

 

1. MEASURED HEIGHT

2. MEASURED WEIGHT

 

 

 

 

3. BLOOD PRESSURE

If high, second reading:

 

 

BLOOD PRESSURE

 

 

 

4.

PULSE

PULSE

 

 

 

VISION

Glasses

Contact Lenses

VISUAL ACUITY

 

COLOR VISION (If required)

5. PERIPHERAL VISION

6. UNCORRECTED

 

CORRECTED

7. ISHIHARA COLOR VISION RESULTS

 

 

o

 

Near

Distant

 

Near

Distant

 

 

 

 

 

 

 

 

 

 

 

Normal

Abnormal

Right

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o

Right 20/

 

 

 

 

 

 

 

 

 

Left

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Left 20/

 

 

 

 

 

 

Plates

# of Plates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Correct

Tested

 

 

 

Both 20/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. HEARING

 

 

 

HEARING AID USED

AUDIOMETRY (If required)

(Ordinary conversation at

YES

NO

500

 

1000

15 feet considered normal)

 

 

 

 

 

 

Right

Left

 

 

Right

 

 

 

 

 

/15

/15

 

 

Left

 

 

 

 

 

 

 

 

 

 

 

2000

3000

4000

6000

9. URINALYSIS:

Specific Gravity

Protein/Albumin

Sugar

10. HEAD (Eyes, ears, TMs, oropharnyx)

11. GENITOURINARY (Note any CVA tenderness)

 

 

12. HEART (Rhythm, murmurs, size, thrust)

13. NERVOUS SYSTEM (Romberg sign, reflexes, motor strength, sensory changes)

 

 

14. LUNGS (Breath sounds, wheezing, rales)

15. SPINE (Appearance, deformity, tenderness, ROM)

 

 

16. ABDOMEN (Tenderness, masses, obesity, inguinal, ventral, or umbilical hernia)

17. UPPER EXTREMITIES (Strength, ROM, deformity, sensory changes)

 

 

18. SKIN AND LYMPHATICS (Scarring, erythema, edema)

19. LOWER EXTREMITIES (Strength, ROM, deformity, sensory changes)

 

 

20. PSYCHIATRIC (Any abnormality noted, affect, mood, speech)

21. VARICOSE VEINS / OTHER VASCULAR ABNORMALITY (Mild, moderate, severe)

 

 

22.ANY WORK LIMITATION (You should review job description/duties) Specify any limitations or needs.

23. PHYSICIAN'S SIGNATURE (Required MD/DO Only)

24. DATE SIGNED

MUST BE SIGNED/CO-SIGNED BY PHYSICIAN.

25.PHYSICIAN'S NAME (Typed or Printed)

PHYSICIAN'S STAMP (Must Include Address and Phone)

PHYSICIAN'S ADDRESS (Required or Use Stamp)

PHYSICIAN'S PHONE NUMBER (Required or Use Stamp)

STATE OF CALIFORNIA − DEPARTMENT OF HUMAN RESOURCES

HEALTH QUESTIONNAIRE

(And Physician’s Report)

STD. 610 (REV 8/2017) (Page 4 of 4)

CONFIDENTIAL MEDICAL DOCUMENT

NOTICE TO PHYSICIANS AND CLINICS

The State of California requires preplacement physical examinations for certain classes of employment. The State also has many employees who are required to have a physical examination at the time of renewal of their Class I or II driver’s license, when the possession of the license is required for the position. If the hiring agency is not identified, do not perform the examination. The California Department of Human Resources does not have the authority to pay for examinations. Please review medical history and comment and sign on Page 2. Also please comment and sign on Page 3.

REPORTS

The medical report should be sent to the Hiring Agency shown on Page 1.

BILLINGS

Please send your bill for this examination to the Hiring Agency as indicated on Page 1. Include your Federal Employer Identification Number or Social Security Number for tax reporting purposes. The State Hiring Agency will pay the fee for this Medical Examination Report up to a maximum determined by the Department of Health Care Services and set forth in the State Administrative Manual (Section 192). The current fee allowance may be obtained from the Hiring Agency shown on Page 1. If there should be additional studies or examinations required for more complete evaluation of the individual, these examinations will be at the expense of the applicant.

PRIVACY NOTICE

Official Responsible: Medical Officer, California Department of Human Resources, 1515 S Street,

North Building, Suite 500, Sacramento, CA 95811; Authority: Government Code Section 18931;

Purpose: The information you furnish will be used to evaluate your medical fitness to carry out the duties of the position applied for without endangering the health and safety of yourself or others; Providing Information: Medical clearance is required prior to employment in state service; Effects of Not Providing Information: Omission or misrepresentation may result in placement in a position where the duties or work environment could be hazardous. A misrepresentation or omission may be cause for adverse employment action; Access: Your medical records will be maintained in a confidential manner and may be reviewed by contacting the employing agency’s personnel office.

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1. When filling out the the std 610 form, be sure to incorporate all necessary blank fields in the relevant section. It will help facilitate the work, which allows your information to be processed efficiently and accurately.

Completing segment 1 of california 610 get

2. Once this array of fields is done, you need to insert the needed details in ITEM, YES, ITEM, YES, Lung or respiratory trouble, Residuals of poliomyelitis, Hepatitis jaundice or other liver, Cancer malignant tumor or cysts, Diabetes or sugar in urine, Pernicious anemia leukemia or, Mental illness, Any disorder of the nervous system, Seizure disorder or loss of, Severe headaches or migraine, and Heart troubleincluding circulatory in order to progress further.

Tips to complete california 610 get portion 2

3. This next part is related to Any problems with hips knees, Any problems with hands elbows or, Fainting spells or dizziness, Skin rash from work, Allergies, Sensitivity to dust or smoke, High or low blood pressure, Varicose veins, Stomach or duodenal ulcer or other, Are you taking any medication now, Have you ever been hospitalized If, a Have you had an illness or, time from work, b Does this illness or injury, and perform certain types of work - type in each of these empty form fields.

b Does this illness or injury, Any problems with hips knees, and perform certain types of work inside california 610 get

4. Your next section will require your information in the following areas: APPLICANT NAME Last, First, Middle, HIRING AGENCY NAME, Please write your own account and, Include DATE OF ONSET YOUR PRESENT, Item, Explanation of YES Items, and Healthcare Provider and Contact. Ensure you provide all requested details to move further.

Part # 4 in filling out california 610 get

People who use this form often get some things wrong when filling out Healthcare Provider and Contact in this part. You should definitely revise what you type in here.

5. To finish your form, the particular area features several extra blank fields. Filling in CERTIFICATION I certify that I, APPLICANTS SIGNATURE, EXAMINING PHYSICIANS COMMENTS, DATE SIGNED, PHONE NUMBER, PHYSICIANS SIGNATURE MD or DO only, DATE SIGNED, DO NOT WRITE BELOW THIS LINE, REVIEWER, APPROVED, DISAPPROVED, SUBJECT TO PROPER PLACEMENT, CalHRs MEDICAL OFFICERS SIGNATURE, DATE SIGNED, and CalHRs MEDICAL OFFICERS NAME Typed will certainly wrap up the process and you can be done very fast!

Step number 5 for completing california 610 get

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