Employee Health Services Consent Form (Desplácese hacia abajo para Español) I am an employee of the xxx and agree to provide my medical history and/or make myself available for a medical evaluation, in accordance with xx’s practices, policies and/or procedures. I understand that a medical history screening and/or medical evaluation will be performed by xxx and xxx, through the xxx. xxx is a medical provider that will provide medical history screenings and/or medical evaluations for xxx to determine my ability to perform job-related functions, to determine whether any restrictions or reasonable accommodations may be necessary, or to determine whether I can perform the job without posing a direct threat to the health or safety of myself or others in the workplace. I understand that my medical history and the results of the medical evaluation will become a confidential part of my medical record to be retained by xxx. I understand that my medical history and records of my medical evaluation, including any medical conditions, will not be disclosed to xxx except as provided below, and will not become a part of my personnel file or educational record, as applicable, at xxx. xxx will, upon my request, provide me with access to my medical records in its possession. I understand and agree that xxx may use my medical history and/or medical evaluation for identification of possible health conditions that may impact my work and/or for the identification of health and safety measures deemed necessary for my work at xxx (including, but not limited to COVID-19 or other infectious diseases). I understand that xxx, after undertaking screening of my medical history and/or a medical evaluation, will communicate to xxx its recommendations regarding health and safety measures it deems necessary for my work, and I consent to such disclosures. xxx may also identify possible health conditions that may impact my work and/or health and safety measures deemed necessary for my work at xxx and report them to the following: (a) first aid and safety personnel, if emergency treatment is necessary; (b) managers and supervisors, to discuss any necessary work restrictions or reasonable accommodations; or (c) government officials, to investigate compliance with federal or state laws. The information may also be released as otherwise required by or permissible under federal or state laws or court orders. I consent to such disclosures. I hereby grant xxx and xxx permission to perform such screenings, examinations, and medical tests as may be deemed professionally necessary or advisable relating to my employment.