Required of all persons upon initial employment, separation from employment for more than one school year, absence of more than 40 consecutive days because of a communicable disease, or when deemed necessary by a local school board or superintendent. (Ref. NCGS 115C-323.)

NAME: ___________________________________________________

SOCIAL SECURITY NUMBER _______________________________
ADDRESS: ________________________________________________
                   ________________________________________________

The above named individual is to be recommended for employment by___________________
(local school board) in a position of _______________. In this position, the condition of certain physical capacities will be of importance.  Please examine the areas listed below and report any limitations, deficiencies or related restrictions.

 I. Communicable Disease

By my signature I certify that the above named person does not have any communicable disease, including tuberculosis, that poses a significant risk of transmission in our schools or would impair this person's ability to perform the duties of the job, except as may be noted above.  Further I certify that this person is free of any other physical or mental disability that would impair job performance.

If unable to certify the above, please comment:

_________________________________________________________________

________________________________________________________________

II.  Other Health Areas

DATE ____________                    _______________________________________________
                                                 Physician, Physician's Assistant, or Nurse Practitioner (type or print)

                                                    SIGNATURE  _______________________________

License/Registration # _________________  State Granting License/Registration: __________