McLean County, IL · McLean County
Conditional Employee or Food Employee Medical Referral
This referral form documents a food employee’s health condition and a health practitioner’s conclusion about whether the employee may work or needs restrictions.
At a glance
- Issued by
- City of McLean County · McLean County, McLean County, Illinois
- Notarization
- Not required: file this form without a notary.
- Official source
- mcleancountyil.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The form is for a conditional employee or food employee referred for medical clearance because of listed symptoms, illnesses, or past typhoid fever. It asks for the employee’s name, the reason for referral, and whether the establishment serves a highly susceptible population. A health practitioner records a conclusion about work eligibility or restrictions, adds any relevant comments, and signs and dates the form.
Who needs it
A conditional employee or food employee referred for medical clearance, and the health practitioner completing the conclusion, use this form.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This form has no notary block; the health practitioner signs and dates the conclusion, and the document does not identify a notarized attachment or related step.
How to submit this form
- 1
Download the Form
Download the Conditional Employee or Food Employee Medical Referral PDF.
- 2
Complete the Referral Details
Identify the employee and check the reason for referral and whether the establishment serves a highly susceptible population.
- 3
Get the Practitioner Conclusion
Have the health practitioner complete the conclusion, add relevant comments, and sign and date the form.
- 4
Submit the Form
Submit it to the county department named on the form; check the county website for current contact details.
Frequently asked questions
- What is the Conditional Employee or Food Employee Medical Referral?
- It records why a conditional employee or food employee is being referred for medical clearance and the health practitioner’s conclusion about work eligibility or restrictions.
- Who completes this referral form?
- The form identifies a conditional employee or food employee being referred. A health practitioner completes the conclusion section and signs and dates it.
- Do I need a notary for this medical referral?
- No. This form has no notary block; the health practitioner signs and dates the conclusion, and the document does not identify a notarized attachment or related step.
- How do I submit the medical referral?
- Submit it to the county department named on the form; check the county website for current contact details.