* = Required Information

Employee Health Risk Assessment Questionnaire

Please Answer the Questions below and return this Questionnaire to Elohim Homecare &Staffing Agency.( If “Yes” please giveexplanation on comment line below)

Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown

Do you currently have:

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

I certify that I have read this document answered all the questions to the best of my Knowledge and Ability

Security code