FORMS- DUE April 11, 2016
(Do not staple, paper clip or double side forms. Original forms must be mailed, scanned/emailed forms will not be accepted.)
All forms must be completed using your legal name as indicated on your Social Security Card.
NOTE: The "Health Statement" requires a physical exam, supporting documentation for TB Skin Tests, labs & vaccinations. Please plan on meeting the requirements while you still have access to healthcare.
Employee Identification Number/Start Date/Date of Hire/Qualifying Event Date will be filled in by HR.
Print, legibly complete and mail all original forms to:
UCSF Fresno Center
Attn: Dyan Ruelas
155 N. Fresno Street, #251
Fresno, CA 93701
For MDs Only
For DOs Only
If Applicable Forms
Nonresident Alien Forms (if applicable)