EMPLOYEE HANDBOOK NOVEMBER 2022

Last Name : _________________________________ First Name : _________________________________ Middle Name : ___________________ First Dose Manufacturer __________________ Lot number: _________________________ Date placed: __________________ Administered by: _____________________ Date read: ______________ Interpretation __________ Read by: _________________________

Second Dose Manufacturer __________________ Date placed: __________________

Lot number _________________________

Administered by: _________________________ Date read: ______________ Interpretation __________ Read by: _________________________

ii IGRA – must provide actual test report

Test date: _____________ Result: _____________ Interpretation date: _____________ Interpretation by: ______________________

b.

History: Does the employee have any of the following: i. History of TB exposure Yes ____

No ____ No ____ No ____ No ____ No ____

ii.

History of TB infection / disease Yes ____ History of TB infection / disease Yes ____ Prior positive diagnostic testing Yes ____

iii. iv.

v.

Prior TB treatment

Yes ____

c. Symptoms Screening: Does the employee have any of the following: i. Chronic cough greater than 3 weeks Yes ____

No ____ No ____ No ____ No ____ No ____

ii.

Night sweats Chronic fatigue Bloody sputum

Yes ____ Yes ____ Yes ____

iii. iv.

v.

Involuntary weight loss

Yes ____

d. General Risk Assessment: Does the employee have any of the following: i.

History of temporary or permanent residence (for >1 month) in a country with a high TB rate (i.e. any country other than Australia, Canada, New Zealand, the United States, and those in western or northern Europe) Yes ____ No ____ ii. Current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with an TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone >15mg/day for >1 month) or other immunosuppressive medication Yes ____ No ____ iii. Close contact with someone who has had TB disease Yes ____ No ____

CERTIFYING PHYSICIAN’S STATEMENT: I have assessed the above named individual. In my judgement, the applicant is free from any physical or mental health impairment; which is of potential risk to patients or might interfere with the performance of his/her duties.

Provider Name:

________________________________________________________________

Address:

________________________________________________________________

City, State, Zip:

________________________________________________________________

Telephone:

Fax: ________________________

______________________________

Physician’s Signature:

Date: ________________________

________________________________________________________

( MD / DO / NP / PA )

*** INITIAL HEALTH ASSESSMENTS MUST BE WITHIN 3 MONTHS OF START DATE*** * Credentialing Department, Clinical Administration Suite * 33 West 42nd Street, New York, NY 10036 * (212) 938-5946 / 5898 * Fax (212) 938-5831

Last Updated 4.2022 79