Please complete as much information as possible.
If the employee works non-standard shifts/cycles, please describe or attach a copy of the shift schedule:
I certify that the information in this form, and any further verbal or written statement provided by me in the future, is true and complete to the best of my knowledge. The information in this statement will be kept in disability case file with arc Health and might be accessible by the employee or third parties to whom access has been granted or those authorized by law. By providing the information I consent to such unedited release of any information contained herein.