EMPLOYEE HANDBOOK

Last Name : ____________________________________ First Name : _________________________________ Middle Name : _________________

First Dose Manufacturer __________________ Date placed: __________________ Date read: ____________________ Second Dose Manufacturer __________________ Date placed: __________________ Date read: ____________________

Lot number: __________________________________ Administered by: ______________________________

Interpretation ________________ Read by: ___________________________

Lot number ______________________________ Administered by: _________________________

Interpretation ________________ Read by: ___________________________

IGRA – must provide actual test report Test date: _____________

ii

Result: ______________________________

Interpretation date: _____________

Interpretation by: ______________________

b.

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

Yes ____ Yes ____ Yes ____ Yes ____ Yes ____

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

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

No ____ No ____ No ____ No ____ No ____

ii.

Night sweats Chronic fatigue Bloody sputum

Yes ____ Yes ____ Yes ____ Yes ____

iii. iv.

v.

Involuntary weight loss

d. 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 Signature:

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: https://form.jotform.com/sunyopt/annual-health-assessment Please contact the Credentialing Department at (212) 938-5946 / 5898 or email at jsanchez@sunyopt.edu / scontreras@sunyopt.edu for any questions. Last Updated 1.2024 84

Last Update FEB 2024