EMPLOYEE HANDBOOK

Please select one:

Staff_________ Faculty _________ Class of _____________

ANNUAL HEALTH ASSESSMENT

LAST : _______________________________________________ FIRST : _______________________________________________ M: __________

IMMUNIZATION / VACCINES ** A copy of blood work results must be provided for titers/immunity documentation . OR

** A copy of the original vaccination document must be provided. RUBELLA (Must be documented by positive titer or date of vaccination ) ( ) Titer Date: _______________ OR

( ) Vaccine Date: _______________ Results: _______________

RUBEOLA (Measles) – ( Proof of immunization is required only for individuals born after 1/1/57 ) ( ) Born before (1/1/57) OR ( ) Titer Date: _________________ Results: _______________ MEASLES VACCINE: ( Two doses of live measles vaccine administered on or after the age of 12 months given at least one month apart ) Date of 1 st Dose: _______________ Date of 2 nd Dose: _______________ TUBERCULOSIS – PLEASE COMPLETE ONE OF THE FOLLOWING THREE OPTIONS:

1) FOR APPLICANT WITH PAST NEGATIVE PPD (Mantoux) skin test results for Tuberculosis: (To be completed and read by: MD/DO/RN/LPN/NP/PA within 48-72 hours of date of injection) Date PPD Applied: _______________

Administered By _____________________________________________________

Date PPD Read:

Result: ________________________

Read By: _________________________

_______________

(MD/DO/RN/LPN/NP/PA) 2) FOR APPLICANT WITH A HISTORY OF POSITIVE PPD (Mantoux) skin test for Tuberculosis: At this examination, does the Individual have any of the following? Chronic Cough (> three weeks) _____ Yes _____ No Night Sweats _____ Yes _____ No Chronic Fatigue _____ Yes _____ No Bloody Sputum _____ Yes _____ No Involuntary Weight Loss _____ Yes _____ No Interpretation Date _______________ Interpretation By: _________________________________ 3) IF YES TO ANY OF THE ABOVE, PLEASE PROVIDE THE FOLLOWING INFORMATION Date of Chest X-Ray: _______________ Result of X-Ray: __________________ (Attach X-Ray Results) QUANTIFERON - TB Gold Test (For individuals with either a history of a positive PPD or those who cannot have a PPD for any reason) Test Date: _______________ Result: ___________________________ Interpretation Date: _______________ Interpretation By: ____________________________________ (MD/DO/RN/LPN/NP/PA)

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 )

*** FOR NEW EMPLOYEES AND STUDENTS, ALL PHYSICALS MUST BE WITHIN 6 MONTHS OF START DATE *** * Credentialing Department * R1005 / R1006 * 33 West 42nd Street, New York, NY 10036 * (212) 938-5946 / 5898 * Fax (212) 938-5831

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APR 2020