EMPLOYEE HANDBOOK NOVEMBER 2022

EMPLOYEE HEALTH ASSESSMENT - ANNUAL

Last Name : ______________________________ First Name : ______________________________ Middle Name : _________________________

Check One:

Faculty

Resident

Staff

IMMUNIZATION / VACCINES (Required for those born on or after 1/1/1957. See attachment for exemptions.) A copy of blood work results must be provided for titers/immunity documentation OR A certificate of immunization required to provide proof of immunity (see attachment for examples of acceptable documentation ) MEASLES (RUBEOLA) - One of the following three requirements must be met for those born on or after 1/1/1957 - a copy of these documents from a previous employer or school can also be used to meet requirement: 1. T wo doses of live measles vaccine administered (with first dose received on or after 12 months and second dose received more than 30 days after the first but after 15 months) Date of 1 st Dose: ________________ Product administered: ___________________________ 2. Physician diagnosis of disease (see attachment for acceptable documentation) 3. Serologic evidence of immunity (copy of blood work required): Titer Date: ________________ Results: ___________ MUMPS - One of the following three requirements must be met: 1. One dose of live mumps vaccine administered (received no more than 4 days prior to the first birthday) Date of 1 st Dose: ________________ Product administered: ____________________________ 2. Physician diagnosis of disease (see attachment for acceptable documentation) 3. Serologic evidence of immunity (copy of blood work required): Titer Date: ________________ Results: ____________ Date of 2 nd Dose: ________________ Product administered: ___________________________

RUBELLA - One of the following two requirements must be met – a copy of these documents from a previous employer or school can also be used to meet requirement:

1. One dose of live rubella vaccine administered (received on or after the age of 12 months)

Date of 1 st Dose: ________________

Product administered: _______________________________

2. Serologic evidence of immunity (copy of blood work required): Titer Date: ________________ Results: ____ __________

TUBERCULOSIS (TB) Serial Screening and Testing (annually after initial onboarding) - Routine annual TB testing no longer required. Rather, an annual risk assessment and symptoms survey must be completed. TB testing required if any symptoms suggestive of TB noted or new risks identified . a. Symptoms Screening: Does the student have any of the following: i. Chronic cough greater than 3 weeks Yes ____ No ____ ii. Night sweats Yes ____ No ____ iii. Chronic fatigue Yes ____ No ____ iv. Bloody sputum Yes ____ No ____ v. Involuntary weight loss Yes ____ No ____

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