State of California
CALIFORNIA CONSERVATION CORPS
CCC HEALTH QUESTIONNAIRE – CONFIDENTIAL
CCC126 (Revised 2/11)
EXHIBIT B
CONFIDENTIAL INFORMATION. The CCC Trainee shall complete and provide this form, the CCC Medical Report (CCC 126-A),
the Pre-Employment Exam Summary (CCC 126-B) and the Corpsmember Job Analysis (CCC 248) to the Medical Provider at the preemployment medical examination appointment. The purpose of the information provided in this form and the pre-employment medical
examination is to determine if the CCC Trainee is able to perform the essential job functions of a CCC Corpsmember with or without
reasonable accommodation. Any omission(s) or misrepresentation(s) of required information made by a CCC Trainee may result in denial
of employment or, if discovered after an offer of employment is made, may result in administrative discipline up to and including
termination of employment with the CCC.
FOLLOWING SECTION TO BE COMPLETED BY CCC REPRESENTATIVE
TRAINEE NAME
(Last)
(First)
CURRENT HOME ADDRESS (Number & Street)
TRAINEE TELEPHONE NUMBER
(Middle)
(City)
ASSIGNED CCC CENTER
(State )
(Zip)
LAST FOUR (4) DIGITS OF SS #
CENTER TELEPHONE NUMBER
CENTER ADDRESS
FOLLOWING SECTION TO BE COMPLETED BY CCC TRAINEE
As a CCC Trainee, you have been provided a conditional offer of employment. To be offered employment with the CCC, you are required to meet the
CCC pre-employment criteria including a pre-employment medical examination. Please answer the following questions to the best of your knowledge.
If you answer “YES” to any question, you are required to provide a written explanation on Page 2 of this form.
Date of Birth:
Approximate Height
Approximate Weight
GENDER
MALE
FEMALE
For questions 1 – 45. Have you ever had or been diagnosed with any of the following:
CONDITION
YES
CONDITION
NO
2.
Lung or respiratory trouble, including bronchitis,
tuberculosis, or asthma?
Residuals of poliomyelitis?
27
History of paralysis or cramps in legs?
3.
Hepatitis, jaundice, or other liver ailments?
28.
4.
Cancer, malignant tumor, or cysts?
29.
5.
30.
31.
Any speech impairments?
7.
Diabetes or sugar in urine?
Pernicious anemia, leukemia, or any other blood disorder
or aliment?
Mental illness or other psychological diagnosis?
Gall bladder problems?
Kidney or bladder problems including blood in
urine?
Shortness of breath?
32.
Any history of addiction to drugs or alcohol?
8.
Any disorder of the nervous system?
33.
Insomnia?
9.
Seizures or loss of consciousness?
34.
Do you wear or have your ever worn glasses?
10.
Severe headaches or migraines?
35.
11.
Heart problems including circulatory disease?
36.
12.
Rheumatic Fever?
37.
Do you or have you ever worn contact lenses?
Have you had any eye injury, eye surgery or eye
disease?
Are you legally blind in one or both eyes?
13.
Any defect of bones or joints including amputations
dislocations, or broken bones/
38.
14.
Rheumatism, arthritis, or bursitis?
39.
15.
Back pain or injury?
40.
16.
Head injury?
17.
Any problems with hips, knees, ankles or feet?
18.
Any problems with hands, elbows or shoulders?
42.
19.
Fainting or dizziness?
43.
20.
Skin rash or eczema?
21.
Allergies including bee stings, poison oak or other?
22.
Sensitivity to dust or smoke?
23.
High or low blood pressure?
24.
Varicose veins?
1.
6.
25.
Stomach or duodenal ulcer or other bowel problems?
26.
Rupture or hernia?
41.
Have you had any difficulty in hearing, inability to
hear and/or wear a hearing aid device?
Do you have any existing temporary medical
condition?
Are you currently under the care of a physician
for any medical condition?
Are you currently taking any medication(s) or
have you taken any medication(s) in the last 12
months?
Have you ever been hospitalized?
Have you ever had an adverse reaction to a drug
or medication?
44a.
Have you had an illness or injury which caused
you to lose time from work?
44b.
Does this illness or injury continue to limit your
ability to perform certain types of work?
45.
Have you ever had any other illness, injury or
physical condition not stated above? If yes, please
specify on Page 2 (Do not include minor illnesses
such as a cold, seasonal flu, etc.)
YES
NO
CALIFORNIA CONSERVATION CORPS
CCC HEALTH QUESTIONNAIRE – CONFIDENTIAL
CCC126 (Revised 2/11)
Page 2
Please provide specific information to explain any response answered “YES” above including, but not limited to, illness, diagnosis,
prescribed medications, dates of hospitalization, name of hospital, etc. Identify your response to a specific question by the noting the
question number above. For instance, if you checked “YES” to Question 4, note below #4 then provide your response.
____________________________________________________________________________________________
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____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
NAME(S) OF MEDICAL PROVIDER WHO TREATED THE
ABOVE-NOTED CONDITION(S).
CERTIFICATION: I certify that the above information is true and correct
to the best of my knowledge. I understand that any omission(s) or
misstatement(s) may result in disciplinary action including termination from
employment with the CCC.
ADDRESS OF MEDICAL PROVIDER
(Street, City, State)
TELEPHONE NUMBER
SIGNATURE OF TRAINEE
DATE SIGNED
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
To:
Any licensed physician, other licensed practitioner, hospital, clinic or other medically related family practitioner, United States
Veterans Administration, military or selective services which are in the possession of medical records pertaining to the person
named on the reverse of this form,
I hereby authorize you to copy and/or transmit to the California Conservation Corps at the address below, any and all medical
records pertaining to my physical and/or mental health with the following exceptions:
_____________________________________________________________________________________
_____________________________________________________________________________________
This authorization shall be for the exclusive purpose of determining eligibility for employment. This authorization is valid for a
period of 180 days after the date of my signature or earlier if revoked by me, in writing, and provided to the California
Conservation Corps.
Send To:
Email To:
Fax To:
Mail To:
California Conservation Corps
Health and Safety Unit - CM Medical Mailbox
8772691532@fax.ccc.ca.gov (1st option)
1 (877) 269-1532
(2nd option)
th
1719 24 Street
Sacramento, CA 95816
(3rd option)
I hereby authorize the release of the above-noted medical records and I am
entitled to a copy of this form, upon written request.
SIGNATURE OF TRAINEE
DATE SIGNED