Fillable Altru EMPLOYEE HEALTH ANNUAL SCREENING FORM

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Altru EMPLOYEE HEALTH ANNUAL SCREENING FORM

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EMPLOYEE HEALTH ANNUAL SCREENING FORM
Employees and Volunteers
Employee: Please complete top portion of form
Name: (PLEASE PRINT)__________________________________ Department: ___________________________
Date of Birth: ___________________________________ Employee Number: ______________________________
1. Do you participate in the hazardous drug program? o Yes o No
(Fill out and submit Hazardous Drug questionnaire)
2. Do you participate in Laser procedures? o Yes o No
Call 701.780.1853 to make an appointment
3. Do you need an ergonomic assessment? o Yes o No
4. Do you know the process to follow if you sustain a work injury? o Yes o No
5. Does your job require that you participate in the Respirator program? o Yes o No
Call 701.780.1853 to make an appointment
6. Does your job require that you participate in the Hearing Conservation program? o Yes o No
Call 701.780.1853 to make an appointment
7. Do you know the 3 key steps to perform with needlestick or blood/body fluid exposure:
__________________________ __________________________ __________________________
Employee Health to complete:
1. Immunizations up to date? o Yes o No
2.
Needs to come in for follow up? o Yes o No
3. Blood Pressure: (optional) _____________________
Employee Health Comments: _______________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Note: This is a confidential form. This record is not made available
to any other person or agency without consent of the employee.
Altru
HEALTH SYSTEM
®
7155-0089 JULY 19
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Altru EMPLOYEE HEALTH ANNUAL SCREENING FORM

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Completed 18 May 2021

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