Fillable New Caregiver Health Screening (City of Oakland)

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New Caregiver Health Screening (City of Oakland)

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1/4/2019
New Caregiver Health Screening
Welcome to Providence St. Joseph Health!
To protect you and our vulnerable patients, certain health requirements must be met before you start work.
Please complete this packet and bring it to your health screening appointment, along with your photo ID
and immunization records.
Immunization and Titer records
Please bring as much documentation as possible regarding the tests and immunizations listed below. This will
prevent the duplication of testing and/or vaccinations. If you do not have documentation, the tests or vaccines
can be provided free of charge.
•
Tuberculosis screening –
• We will accept documentation of a current (within the last 30 days) Interferon Gamma
Release Assay (IGRA), which is a blood test for TB, QuantiFeron TB Gold or T Spot.
• Where TB skin testing is performed, a two- test process is required. We will accept
documentation of a TB skin test (TST) performed within the last 12 months for the first step
and perform a second test during the pre-employment health screen.
• Positive TB history: If there is a history of positive TST or IGRA, please bring that
documentation as well as a copy of your chest x-ray report (Baseline CXR performed after positive
TB test) and medical provider documentation of evaluation.
•
Measles, Mumps, and Rubella (MMR) – Documentation of two MMR vaccines at least 4 weeks apart and after
one year of age and/or positive laboratory titers
•
Chickenpox (Varicella) – Documentation of two Varicella vaccines 4 weeks apart and after one year of age
and/or positive titer
•
Hepatitis B (Hep B) – History or documentation of Hep B vaccinations (series of 3) and
positive laboratory titer as required in accordance with ministry or regional policy
•
Tetanus, Diphtheria and Pertussis (Tdap) – Documentation of vaccination
•
Annual Influenza vaccine – Documentation of acceptance or signed declination of the vaccine
•
Fit Test Record– Please bring prior record indicating N95 respirator brand and size and/ or PAPR training
and testing record within the last twelve months
If you need help obtaining your immunization records, check with your physician, previous employers, schools or
contact the health department where you grew up. You may also call your state’s immunization information system
helpline:
•
Alaska
888-430-4321
•
California
800-578-7889
•
Montana
406-444-5580
•
Oregon
800-980-9431
•
Washington
866-397-0337
•
Texas
800-252-9152
•
New Mexico
800-280-1618
We strongly encourage you to gather your records as soon as possible.
It may take several weeks to obtain your records.
Please bring all your records to your health screening appointment.
1/4/2019
Caregiver Screening Form
Name:
Date of Birth: _____________
Last
First
Middle
Address: City:
State: ______ Zip:
Email
address:
Phone
number:
Alternate phone number:
Best
time to call: Supervisor: __________________________
Region:
Facility/Department
: ___________________________________
Position: ________________________________________
Please complete the following to the best of your knowledge. This will become a part of your caregiver health file. All
medical information is confidential. If you have any questions please call
Caregiver Health Services (CHS).
Yes No
If applicable, are you willing and able to wear required safety equipment such as
gloves, glasses, respirators, masks or ear protection on the job?
If no, please explain:
Yes No
I have been provided and understand the detailed position description and I am
mentally and physically capable of performing the essential functions of the
position being hired for.
Yes No N/A
If you answered no to the previous statement, would accommodations allow you
to
perform the essential functions?
If yes, please specify accommodations required:
Yes No
Are you taking medications which may impact your ability to safely perform the
functions of your position or otherwise pose a safety concern?
Yes No N/A
If you are being hired in Oregon or Washington, have you been placed in the
Preferred Worker Program under workers’ compensation laws?
Yes No
Have you ever had any reaction to any latex product (e.g., rash, swelling, anaphylaxis,
burning after contact)?
If yes, please describe:
Yes No
Have you ever had any reaction to (please circle any that apply): avocado, banana,
chestnuts, egg, kiwi, milk, papaya, passion fruit, peach, potato, or tomato?
If yes, please describe:
Yes No
Do you have any communicable condition that may be potentially transmitted to
others in the hospital or health care setting?
Applicant signature: Date:
Reviewed by: ______________________________________________ Date: ______________________
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TUBERCULOSIS SCREENING QUESTIONNAIRE
Name: ______________________________________ Date of Birth: ________________ Caregiver ID #:_____________
Last First Middle
Dept: _______________________________________ Home/Cell Phone #: _____________________________________
Caregiver/Applicant Volunteer Other: __________________________________________________________
DO YOU CURRENTLY HAVE SYMPTOMS OF:
If yes, please explain
1. Persistent and/or productive cough for three weeks or longer?
Yes
No
2. Cough for more than one week following confirmed TB exposure?
Yes
No
N/A
3. Prolonged low grade fever associated with cough for more than 1 week?
Yes
No
4. Blood present in sputum?
Yes
No
5. Unexplained night sweats (unrelated to menopause)?
Yes
No
6. Unusual fatigue for more than two weeks?
Yes
No
7. Loss of appetite for more than two weeks?
Yes
No
8. Unexplained weight loss of five pounds or more?
Yes
No
CURRENT HEALTH STATUS:
If yes, please explain
9. Do you have an acute viral infection or febrile illness?
Yes
No
10. Have you had a live-virus vaccine in the past four weeks?
Yes
No
11. Are you on or planning to begin immunosuppressive therapy or treatment: including
human immunodeficiency virus (HIV) infection, organ transplant recipient,
undergoing radiation therapy, chemotherapy, treatment with a TNF-alpha antagonist
(e.g., Infliximab, etanercept, or other), chronic steroids (equivalent of prednisone >15
mg/day for >1 month) or other immunosuppression medication? (*)
Yes
No
12. Do you have diabetes?
Yes
No
HISTORY:
If yes, please explain
13. Have you lived or visited (more than one month) in a country with a high TB rate?
(Any country other than the United States, Canada, Australia, New Zealand and those
in northern Europe or Western Europe). (*)
Yes
No
14. Have you had unprotected close contact with someone who has had infectious TB
disease in the past 12 months or since your last TB test? (*)
Yes
No Relationship:
15. Have you received the BCG vaccination?
16. Have you ever had a positive TB skin or blood test?
Date:
17. Have you had a chest x-ray related to TB?
Date:
18. Have you ever been treated with TB medications?
Yes
No
Please note: HIV infection and other medical conditions may cause a TB test to be negative even when TB infection is present. Persons with HIV
infection and certain other medical conditions that may suppress the immune system are at significant risk of progressing to TB disease if they have
TB infection. If you have HIV infection or other medical conditions that may suppress the immune system, discuss your risk of TB with your primary
care provider.
To my knowledge, the above information is correct. I consent for an IGRA (TB) blood test, and/or chest x-ray.
Applicant/Caregiver Signature: ______________________________________ Date: _________________________
For Clinic Use Only
(*) Risks: if any one question is marked yes, refer back to TB algorithm.
(!) Any questions 1-8 marked positive refer to TBQ Scoring Grid Standard Work.
Caregiver Health Nurse Review: Based on current TB algorithm, I have reviewed the above and recommend:
IGRA TST Symptom review only
Caregiver Health Nurse Name (print): _______________________________ Signature: ____________________________ Date: ______________
IGRA: Draw Date: ________Review Date: ________ IGRA Results: Negative Positive
IGRA: Draw Date: ________ Review Date: ________ IGRA Results: Negative Positive
Follow-up Action: No further follow up needed CHN Name: _______________________________
CXR ordered; Date: _________ Results: Negative Positive CHN Name: _______________________________
For known history of positive TB test: TST on file? Yes No Date: __________ If yes, IGRA drawn? Yes No
IGRA on file? Yes No Date: __________
CXR on file? Yes No Date: __________ Results: Neg Pos 11/13/2019
1/4/2019
Consent and Release of Medical Information
Name:
_ Date of Birth:
Last First Middle
I authorize the Providence St. Joseph Health (PSJH) or Kadlec designee(s) to administer
immunization(s), TB skin testing/TB blood testing, and other preventative, or diagnostic
treatments for illness or injury sustained during the course of my work. This authorization also
includes treatment for minor non-industrial injuries/illnesses.
This authorization does not prevent me refusing treatment at a later date. It remains in effect
during my employment at any PSJH or Kadlec facility. Commonly administered injections may
include Tuberculosis skin test, Tetanus & Diphtheria, Tetanus, Diphtheria & Pertussis,
Hepatitis B, Hepatitis A, MMR (Measles, Mumps & Rubella), Varicella, Meningococcal and
Influenza. Additional testing may be ordered, such as chest x-rays or lab testing.
For your continuity of care, all of your laboratory and diagnostic imaging reports ordered by
Caregiver Health will become a part of your electronic Caregiver Health record.
All individually identifiable information in the employee health record is maintained in the
Caregiver Health Services (CHS) department in accordance with state and federal statutes and
regulations. Information will be disclosed if that information is deemed relative regarding
suitability for employment, ability to perform essential job functions or significant job change or
transfer.
In the event of a work related injury/illness sustained during employment at PSJH and Kadlec,
information may be provided to those involved in the administration of your Workers
Compensation Claim.
• Work related incidents/injuries need be reported to your Core Leader and submitted
through the HR Portal*
• Blood, body fluid, or communicable disease related exposures also must be reported
to Caregiver Health, your Core Leader and submitted through the HR Portal*
*Covenant caregivers, please follow local injury reporting process
I hereby certify that the above statements are true to the best of my knowledge and that intentional
misstatements may result in the withdrawal of my conditional offer or the immediate termination of
my employment. I consent to post-offer health screening and test by a physician or other qualified
health professional appointed by PSJH or Kadlec, if necessary. I understand that any information
disclosed during this pre-employment health screen and the results of this health screen will be
provided to the PSJH ministry, affiliate and/or clinic where I am employed. By my signature below, I
am expressly authorizing disclosure of this information with my ministry, affiliate and/or clinic
employer.
Applicant Signature: Date:
CHS Representative: Date:
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Completed 14 June 2021

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