Geneva C
Employee Name: ___________________________Position: ___________________________Geneva C.U.S.D. 304Certificate of Physical Fitness/Health ExamTo: Employee and PhysicianRequirement for EmploymentIllinois School Code, Chapter 122.24-5 indicates "School Boards shall require of new employees evidence of physical fitness to perform duties assigned and freedom from communicable disease. Such evidence shall consist of health examination made by a physician licensed in Illinois or any other state to practice medicine and surgery in all its branches not more than 90 days preceding time of presentation to the board and cost of such examination shall rest with the employee."Physician's CertificateI certify that I have examined __________________________________ and find this person is able to perform the duties assigned.Physician's Signature: Address: Tuberculum Test Results__________ Negative__________ PositiveDate: ................
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