Fair Oaks Recreation & Park District - Certification of TB Tests

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CERTIFICATION OF TUBERCULOSIS

Contractor

First name *

Last name *

Email *

____________________________ ("Contractor") acknowledges that pursuant to California Public Resources Code §5163 that no person (e.g., employee of Contractor, volunteer, or independent contractor or subcontractor hired by Contractor) shall initially be employed in connection with a park, playground, recreational center, or beach used for recreational purposes by a city or county in a position requiring contact with children, or as a food concessionaire in that area, unless the person produces or has on file with the city or county a certificate showing that within the last two years the person has been examined and has been found to be free of communicable tuberculosis.
Contractor certifies that Contractor has received a “Certificate” from each person below to verify that within the last two years the person has been examined and has been found to be free of communicable tuberculosis. An annual chest X-ray is required if the person is unable to take a TB test due to possible past exposure.

I have read and accept *

Name of Employee(s) | Position | Test Results, Read Date | Chest X-Ray (if ncessary) *

Electronic signature

Contractor is required to provide updated information to the District as employees change and as test results are updated. Contractor further acknowledges that by this Certification of Tuberculosis Result, Fair Oaks Recreation & Park District will not independently verify the information provided by Contractor; so therefore the Contractor shall indemnify, defend and hold harmless the District, its elected and appointed officials, and its employees from and against any and all claims, loss, liability and damages resulting from injury or death to any person arising out of or in connection with the misrepresentation of any information provided herein.

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4150 Temescal Street, Fair Oaks, CA, 95628, US 916-966-1036

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