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GENESYS Name:
S Y S T E M S I N T E G R A T O R
Post-Offer Employment Questionnaire
Notice: You have been selected for employment by GENESYS and an offer has been extended for such employment.
This questionnaire is a post-offer requirement. Refusal to answer any of the questions could disqualify the Company's
offer of a job opportunity and/or result in your termination.
Full Name Social Security Number:
Signature Date
(Explain all yes answers to the following Questions on page 2 - Continuation Sheet) YES NO
1 . Have you ever had surgery on your back or seen a physician regarding back pain?
2 . Have you ever had surgery on your knee(s), or seen a physician regarding knee pain?
3 . Have you ever had surgery on your shoulder(s), or seen a physician regarding shoulder pain?
4 . Have you ever had surgery on your neck, or seen a physician regarding neck pain?
5 . Have you ever had surgery on your feet, or seen a physician regarding foot pain?
6 . Have you ever been treated by a physician for an injury covered by a worker's compensation insurance plan?
7 . Do you have any injuries that you are currently receiving treatment for?
8 . Have you ever had surgery or seen a physician for any ailment of the heart or circulatory system, such as By-
Pass surgery, heart attack, or transplant?
9 . Have you ever had surgery on or been treated for an abdominal condition such as a hernia?
10 . Are you aware of any other medical conditions that could jeopardize or inhibit your ability to perform highly
strenuous work?
11 . Have you received any instruction in an OSHA-approved CPR course?
12 . Have you been certified under the OSHA 10-Hour Construction Safety Course?
13 . Do you experience any dizziness, nausea, headaches, or vision problems when working in the air (with
scaffolding, lanyards, ladders, scissorlifts, etc.)?
14 . Do you have any known allergies?
3210 E 85th St GENESYS
Kansas City, MO 64132
www.GENESYScorp.net Wednesday, December 28, 2016
Phone: (816) 525-7701
Fax: (816) 525-7720
