EMPLOYEE HANDBOOK NOVEMBER 2022

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

b. General Risk Assessment: Does the student 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 PHYS ICIAN’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 )

** ANNUAL HEALTH ASSESSMENTS ARE DUE BY NOVEMBER 30 th AND MUST BE WITHIN THE SAME CALENDAR YEAR ** * 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

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