EMPLOYEE HANDBOOK

EMPLOYEE HEALTH ASSESSMENT (INITIAL)

Last Name : _____________________________________ First Name : _____________________________________ Middle Initial : ____________

a.

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

Yes ________ Yes ________ Yes ________ Yes ________ Yes ________

No ________ No ________ No ________ No ________ No ________ No ________ No ________ No ________ No ________ No ________

ii.

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

iii. iv.

v.

Prior TB treatment

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

ii.

Night sweats Chronic fatigue Bloody sputum

Yes ________ Yes ________ Yes ________ Yes ________

iii. iv.

v.

Involuntary weight loss

c. 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 HEALTHCARE PROVIDER’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: ________________________ Healthcare Provider’s S ignature:

Date: _______________________

________________________________________________________

(MD / DO / NP / PA)

*** INITIAL HEALTH ASSESSMENTS MUST BE WITHIN 3 MONTHS OF START DATE*** This form must be completed & uploaded, along with all supporting documents, to the link below: https://form.jotform.com/sunyopt/health-assessment Please contact the Credentialing Department at (212) 938-5946 / 5898 or email at jsanchez@sunyopt.edu / scontreras@sunyopt.edu for any questions or concerns.

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MAR 2026