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Physical Examination








Worcester State University has established a pre-employment medical examination policy for designated job classifications.  This policy will be used to establish prospective employee’s fitness to perform the jobs for which they have applied.

For each job classification listed below, candidates will be offered employment on a conditional basis, pending the results of a work-related medical examination.  Other classifications may be added as WSU deems advisable:

Maintainer Series

Grounds Workers

Mail Clerks



Skilled Trades

Skilled Laborers

University Police







1.    All applicants and transfers from another job classification, unless they have previously passed probation in the classification, will be required to submit to a Pre-employment Medical Examination.


2.    All medical examinations will be performed by medical and/or physical therapy practitioners as designated by WSU, and will be paid by the University. Only job-specific information, based on the job description, will be given to WSU by the physician.


3.    Position announcements for jobs in these classifications are to state, “Job will be offered on condition of meeting the predetermined essential physical requirements for the job.  A medical examination is required.”


4.    At the time of verbal offer, the applicant will be advised that, as a condition of offer for the position, WSU will require the applicant to have a medical examination to evaluate his/her ability to perform the essential job functions.


5.    Once a verbal offer has been made, a written Letter of Offer will be prepared and mailed to the applicant.  This letter will indicate that the position has been offered on a conditional basis, contingent upon the satisfactory results of a medical examination.  The results will be considered satisfactory if it is determined that the applicant can perform the essential functions of the position, with or without accommodation.  


The offer letter will explain how medical examination appointments are arranged and that failure to appear for the medical examination may be considered a rejection of the conditional job offer.   The Medical Examination Consent Form will be enclosed.  The applicant will fill out one section, the physician, the other.  Upon completion, this form will be returned to WSU Human Resources.


A copy of the Letter of Offer and the Job Description form will be sent to the physician conducting the examination, notifying them that WSU has extended a conditional offer and the need for this applicant to have a pre-employment medical examination.

     All applicants who receive a verbal job offer and have a satisfactory result on the medical

     examination are to be hired.


6.    If the medical examination is not satisfactory WSU may withdraw the offer of employment. Disqualification from the job offer will be job related and consistent with business necessity, including, but not necessarily limited to, failure to meet the physical requirements, inability to perform the essential functions, with or without accommodation, posing a direct threat to the safety of themselves or others, or if accommodations would place an undue hardship on the University, in accordance with the American’s with Disabilities Act. Requests can be made to Office of Human Resources to learn the reasons for withdrawal of the job offer.


7.    Worcester State University is committed to compliance with the American’s with Disabilities Act.








Consent Form

Confidential Record


Worcester State University

Human Resources

486 Chandler Street

Worcester, MA 01602

Medical Examination Consent Form


Note to applicant:

The position for which you are applying is one in which candidates who have received conditional job offers are required to have a medical examination. Medical examinations are an important part of the selection process.  Information provided by this report will be released only to authorized persons involved in the employment decision.


Worcester State University is committed to making all reasonable accommodations necessary to comply with the ADA.                                                                                                                              

To be filled out by the applicant after the conditional job offer has been made:

Title of the position for which you are applying:                                                                                      

Full name (please print):                                                                                                                          

Street address:                                                                                                                                        

City, State, Zip:                                                                                                                                        

Social Security #:                                                                                                                                    

I agree that Reliant Medical Group may release this information to the Worcester State University in order to verify that I am able to perform the essential duties of the job.  I understand that failure to appear for the medical examination may be considered a rejection of the job.  I understand that the medical examination given is solely for the benefit of  WSU and not the benefit of myself.  I understand that I may be referred to my health care provider if further evaluation is needed.  I understand that it may occasionally be necessary for Reliant Medical Group to contact my health care providers for job-related medical information.  I authorize my current health care provider to release this information to Reliant Medical Group.


Employee Signature:                                                                                            Date:                          


To be filled out by the Reliant Medical Group Physician:


Will the candidate be able to perform the essential functions of the job as outlined in the job analysis?

                  Yes                                                      No                        

                  Does the applicant have any physical limitations or restrictions?  If so, please identify.



Will the candidate need any accommodations to perform the essential functions of the job as outlined in the job analysis?

                  Yes                                                      No                        

                  If yes, what accommodations are recommended?



Doctor’s Signature and Date:                                                                                                                  

Doctor’s Name (please print):                                                                                                                 

Reliant Medical Group will return the original copy of this form to WSU Human Resources, at the address indicated above.


Approved by


Approval Date


Revised Date

May 10, 2013




Last modified at 10/15/2013 1:21 PM  by Hoxha, Anisa