EMPLOYEE HANDBOOK

EMPLOYEE HEALTH ASSESSMENT (INITIAL)

Last Name : _____________________________________ First Name : _____________________________________ Middle Initial : ____________ Circle One: Faculty Resident Staff IMMUNIZATION / VACCINES ( See attachment for exemptions ) A copy of the MMR immunization record or a copy of blood work results must be submitted. (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. Two 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: ___________________________

Date of 2 nd 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: _______________________________________ 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) Baseline (Onboarding) Assessment and Testing: ** Testing required and must be done within 3 months of first day on campus (unless documentation of prior Latent TB or TB disease) ** 1. Initial assessment should include TB testing (when not contraindicated). TB history, review of symptoms and general risk assessment. a. Testing – Interferon-Gamma Release Assay (IGRA) only . Positive tests must be followed up with a chest x-ray and other clinical follow-up as indicated to rule-out active disease. i. IGRA – must provide actual test report

Test date : ______________________________

Result: ______________________________

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MAR 2026