To Be Used for Insurance Purposes Only
Dept/ Pos. No:
1. Epilepsy2. Diabetes3. Cardiac disease 4. Arthritis5. Amputated foot, leg, arm, or hand 6. Loss of sight of one or both eyes or partial loss of more than 75% bilateral 7. Any disability resulting from polio 8. Cerebral palsy 9. Multiple sclerosis 10. Parkinson's disease 11. Stroke 12. Tuberculosis13. Silicosis (lung disease)14. Psychoneurotic disability 15. Hemophilia (free bleeding)16. Chronic osteomyelitis (inflamation of the bone) 17. Hyperinsulinism18. Muscular dystrophy 19. Hardening of the arteries20. Thrombophlebitis (blood clots)21. Varicose veins 22. Heavy metal poisoning 23. Ionizing radiation injury 24. Compressed air sequelae 25. Ruptured disc26. Ankylosis of joints 27. Hodgkin's disease 28. Brain damage29. Deafness 30. Cancer 31. Sickle cell anemia 32. Pulmonary disease (lungs)
I understand this questionnaire is for the purpose of enabling Clemson University to fulfill the requirements of the South Carolina Second Injury Fund. The information provided is not to be used by Clemson University as a basis of denying me placement within the company or promotion, or to discriminate against me in any way. By submitting this form, I attest that the information provided is true to the best of my information and belief.
Note: The above information is for official use only and will not be released to unauthorized persons.
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