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:

b.

History: Does the employee have any of the following: i. History of TB exposure Yes ii. History of TB infection / disease Yes iii. History of TB infection / disease Yes iv. Prior positive diagnostic testing Yes v. Prior TB treatment Yes

No No No No No

c. Symptoms Screening: Does the employee have any of the following: i. Chronic cough greater than 3 weeks Yes No ii. Night sweats Yes No iii. Chronic fatigue Yes No iv. Bloody sputum Yes No v. Involuntary weight loss Yes No 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/health-assessment 2

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Please contact the Credentialing Department at (212) 938-5946 / 5898 or email at jsanchez@sunyopt.edu / scontreras@sunyopt.edu for any questions.