1. Medical Assistant Online Data Sheet Form

 

Required Information

First Name
Last Name
E-mail
Home Phone
include area code
Work Phone
include area code
 Address
City
State
Zip Code
Name of surrounding hospitals 1.

2.

3.

Do you have transportation? Yes No
Type of Transportation
(bus, car, or other)
Do you have basic medical insurance coverage? Yes No
Are you CPR certified? Yes No
Did you complete a 4 hour HIV/OSHA class? Yes No
Do you have any type of disability? Yes No
If so, what type?
Are you currently working? Yes No
  Full Time  Part Time
Are you currently working for a physician? Yes No
If you are working, please tell us days and hours of employment

If you have any problems submitting this form, send a message to webmaster@keiseruniversity.edu