Start Date Medical Information

Caterpillar Confidential: Green Updated: **/**** Printed copies are uncontrolled documents

Office Use Only

Candidate Name: Hiring Facility:

SSOS Contact/

Recruiter

Date of Employment

Offer:

Desired Start Date:

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of employees or their family members. To comply with this law, we ask that you not provide any genetic information when responding to this request for medical information. “Genetic information”, as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, and the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Post Offer Medical Questionnaire Instructions:

Please read and sign before completing the questionnaire As part of our continuous efforts to maintain a safe working environment, Caterpillar Inc. is focused on supporting the safety and well being of the people we employ. In order to provide safe and proper placement within your position at Caterpillar Inc., it is very important for you to honestly complete the following medical questionnaire. Be sure to include all past and current injuries and/or medical conditions.

Failure to provide honest disclosure of any present or past medical conditions will be considered as a falsification of the medical questionnaire, and can result in the withdrawal of your employment offer, or disciplinary action up to and including termination of employment.

If you have any questions regarding the medical questionnaire, please ask for further clarification. When filling out the Post Offer Questionnaire:

• Print your full name on each page

• List your phone number with area code. This should be a number where we will be able to contact you if we have any questions

• Answer all questions with a circle of yes or no

• If you answer “yes” to a question, list:

- Approximate date

- Body location

- Brief description of event

By signing this form, you acknowledge that you have read these instructions and understand the importance of providing complete and honest answers to the information requested on the attached medical questionnaire. Print Name Sign Name Date

HR Manager

Job Title:

Caterpillar Confidential: Green Updated: 02/2022 Printed copies are uncontrolled documents CATERPILLAR INC. – Post Offer Questionnaire Page 1 of 3 Name: Date: Email:

Address: City/St/ZIP:

Age: Birthdate: Cell #: Height: Weight: Sex: Male Female Phone #: Please answer ALL of the following questions. Provide as much detailed information as possible to facilitate your placement. (please print clearly)

1. Do you have any allergies? (medications, foods, skin contact, environmental or Yes No workplace – ex. bee stings, chemicals, soaps, metals, or oils) If yes, please list and describe type of reaction. 2. Do you take any prescription or over-the-counter medications? Yes No If yes, please list. 3. Are you currently under a doctor’s care? Physician name: Yes No If yes, please explain what you are being treated for: 4. Do you have or have you ever had any of the following medical conditions: High blood pressure? If yes, Please list your most recent blood pressure reading: Heart disease (heart attack, angina/chest pain, heart failure, irregular heart rhythm, or any other heart condition?) Do you have a pacemaker or internal defibrillator? Asthma/lung disease? Hepatitis/liver disease? Diabetes/sugar problems? Have you had a hypoglycemic/low blood sugar episode? If yes, when? Epilepsy/seizure disorder? If yes, when was your last seizure? Bleeding disorder? Skin rash? Sleep apnea, sleep disorder, or daytime sleepiness? Migraine or severe headaches? Groin pain, lump in groin, or rupture/hernia? ANY other medical condition?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If yes, please explain condition and provide details about treatment. 5. Have you ever had any surgeries or operations?

Operation on hernia/rupture? Operation on a muscle or tendon? Operation on a bone or joint? Operation on back or neck? ANY other type of operation? Yes No

Yes No

Yes No

Yes No

Yes No

If yes, please list and give approximate dates. Caterpillar Confidential: Green Updated: 02/2022 Printed copies are uncontrolled documents CATERPILLAR INC. – Post Offer Questionnaire Page 2 of 3 Name: 6. Are you currently smoking or using any type of tobacco product? Yes No If yes, please state how much you smoke/chew. 7. Have you ever smoked or used tobacco products? Yes No If yes, please state when you started, when you quit and how much you used each day. 8. Have you ever been treated by a psychiatrist or psychologist? Yes No If yes, please explain and indicate if you are still under active care. 9. Do you have or have you ever had: Depression, panic attacks, anxiety, fear of heights, Yes No or confined spaces?

If yes, please explain. 10. Have you ever blacked out, fainted, or become dizzy or light headed? Yes No If yes, describe the condition and when it occurred. 11. Do you have or have you ever had ANY back pain or injury? Yes No If yes, please explain if this is a past or current problem. Describe the location (low, mid or upper back) and specify any treatment, medication or physical therapy. 12. Do you have or have you ever had ANY neck pain/injury or a head injury? Yes No If yes, please describe. 13. Do you have or have you ever fractured (broken) a bone? Yes No If yes, please describe location and treatment received. 14. Do you have or have you ever had ANY weakness or numbness and tingling in your hands, arms, legs, or feet? Yes No

If yes, please describe. 15. Do you have or have you ever had carpal tunnel syndrome? Yes No If yes, explain any treatment you received. 16. Do you have or have you ever had ANY pain or injury in your shoulder (rotator cuff, impingement, dislocation, or separation)? Yes No If yes, please explain. 17. Do you have or have you ever had ANY pain or injury in your elbow, wrist, or hands Yes No

(Tennis elbow, wrist sprain, ganglion, cubital tunnel, tendon injury, tendonitis, finger or nail injury, or arthritis.) If yes, please describe and when occurred: 18. Do you have or have you ever had ANY pain, injury or other problems in your hip, knee, Yes No or ankle. (Torn ligament or cartilage, ankle sprain, arthritis, degenerative joint disease, etc.)? If yes, please describe and when occurred. 19. Do you have or have you ever had any type of foot problem (heel pain, plantar fasciitis, Yes No bunions)? If yes, please describe and when occurred 20. Do you have or have you ever been diagnosed with any type of arthritis? Yes No

(Osteoarthritis, rheumatoid, etc.)

If yes, please describe and when occurred 21. Have you ever consulted with an orthopedic surgeon, neurosurgeon or chiropractor? Yes No If yes, please describe condition treated. Caterpillar Confidential: Green Updated: 02/2022 Printed copies are uncontrolled documents CATERPILLAR INC. – Post Offer Questionnaire Page 3 of 3 Name:

22. Please answer the following about your previous work experience: Worn a respirator to do a job? Yes No

Worked with or near asbestos? Yes No

Worked with air tools or vibratory tools? Yes No

Please explain any yes answers. 23. Please answer the following about your eyesight: Do you have clear vision in both eyes?

Do you wear glasses or contact lenses?

Do you have to wear glasses or contacts to drive?

Are you colorblind?

Yes No

Yes No

Yes No

Yes No

Please explain any other conditions you have with your eyes. 24. Please answer the following about your hearing: Do you have any type of hearing loss?

Do you wear a hearing aid?

Have you worked in a high noise job?

Have you ever worn or do you currently wear hearing protection in noisy environments? Yes No

Yes No

Yes No

Yes No

Please explain any problems with your hearing. 25. Do you have any other health conditions that have not been covered in this questionnaire? Yes No If yes, please describe. 26. Do you feel that you need any work accommodations or restrictions based upon a Yes No medical condition to perform job tasks?

If yes, please describe: 27. What exercise or activities (hobbies) do you do outside of work? 28. Are you currently pregnant? Yes No

I certify the above information is true and correctly recorded. I understand that any false, misleading, or incorrect statements will be cause for immediate dismissal. I understand that placement may require additional time if further medical information is required. Signature: Date: Reviewed by: Date:

(Nurse Signature)

Progress Notes Attached Asthma Questionnaire Attached

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