EMPLOYEE HANDBOOK

Last Name : ______________________________ First Name : ______________________________ Middle Name : _________________________

b. 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 )

*** ANNUAL HEALTH ASSESSMENTS ARE DUE BY NOVEMBER 30 TH AND MUST BE WITHIN THE SAME CALENDAR YEAR *** This form must be completed & uploaded, along with all supporting documents, to:

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.

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Last Update Jan.2025