EMPLOYEE HANDBOOK

EMPLOYEE HEALTH ASSESSMENT - INITIAL

Last Name : _________________________________ First Name : _________________________________ Middle Name : ___________________

Circle 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 if a certificate of immunization is not available (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: ___________________________

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 – must have either Tuberculin Skin Test (TST) or Interferon-Gamma Release Assay (IGRA) - positive tests must be followed up with chest x-ray and other clinical follow-up as indicated to rule-out active disease i. TST – two-step testing required (as long as initial test is negative) – second dose can be administered 1-3 weeks after initial test – only one test required if employee has another negative documented test during previous 12 months

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