PRIOR INJURY AND DISABILITY QUESTIONNAIRE

The information requested in this questionnaire is being requested solely for purposes of determining the applicant's ability to perform the duties of the position for which they are applying. This information will be kept confidential and separate from the personnel file and will not be used to discriminate against you in any way.

Please answer the following questions truthfully and completely. If you answer "yes" to any condition below, provide additional details regarding the nature, extent, and treatment of the injury or condition.