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/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.
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Last Update FEB.2024
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