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PRE-EMPLOYMENT PHYSICAL OCCUPATIONAL HEALTH QUESTIONNAIRE (UCLA Health)

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  • 17 check-boxes
  • 136 other fields

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PRE-EMPLOYMENT PHYSICAL
OCCUPATIONAL HEALTH QUESTIONNAIRE
Print Forms and Complete All Quesons
I have reviewed the descripon of the job for which I am applying.
X Signature Date
Do you have any condion, illness, injury, or are you taking any medicaon that aects any of the following job related
for your posion as idened in your job descripon?
(Please answer ONLY the specic quesons below that relate to the essenal funcons of the job for which you are applying, as
outlined in your job descripon.)
VISION
Do you have any impairment of vision which is not correctable?
Yes No Please explain ____________________________________________________________________________
HEARING
Do you have any impairment of hearing which is not correctable?
Yes No Please explain ____________________________________________________________________________
SPEECH
Do you have any impairment which interferes with your ability to communicate with others?
Yes No Please explain ____________________________________________________________________________
MOVEMENT & STRENGTH
Do you have any impairment of the following body parts:
Yes No Please explain _________________________________________________________________
SHOULDER OR ELBOW
Yes No Please explain _________________________________________________________________
HAND OR WRIST
Yes No Please explain _________________________________________________________________
FOOT OR LEG
Yes No Please explain _________________________________________________________________
NECK
Yes No Please explain _________________________________________________________________
BACK
Connued on next page
Page 1 of 7
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PRE-EMPLOYMENT PHYSICAL
OCCUPATIONAL HEALTH QUESTIONNAIRE
(Connued)
BREATHING
Do you have any problems with your breathing?
Yes No Please explain ____________________________________________________________________________
CARDIAC
Do you have any condion or medicaon which would limit you?
Yes No Please explain ____________________________________________________________________________
BALANCE AND/OR CONSCIOUSNESS
Do you have any condion or medicaon that can aect your balance and/or consciousness?
Yes No Please explain ____________________________________________________________________________
Page 2 of 7
PSYCHOLOGICAL AND/OR EMOTIONAL DISORDERS
Yes No Please explain ____________________________________________________________________________
ALLERGIES (example Latex, Peanuts, Penicillin, etc.)
Yes No Please list _______________________________________________________________________________
________________________________________________________________________________________
ANY OTHER CONDITION(S) that would limit your ability to do any of the essenal job funcons as
described in the job descripon?
Yes No
If yes, please explain ______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
I aest that the above is try to the best of my knowledge.
X Signature Date
3/1/18
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PRE-PLACEMENT
TUBERCULOSIS SCREENING
Name: ________________________________________________________
PLEASE ANSWER ALL QUESTIONS
Yes No
Page 3 of 7
1) I have a history of a posive TB Skin Test, T-SPOT, or QuanFERON Blood Test:
X Signature Date
9/28/18
Date of Birth: ___________ Cell Phone Number: _____________________
Email Address: _________________________________________________
Hiring Dept: ______________________________________ Sta ID (if any): _________________________
Yes (complete informaon below) No
2) I have taken INH or other medicaon in the past for TB infecon or disease:
Dates: ____________ Number of Months: _______ Medicaon: __________________________
Yes (list countries) No
3) I was born, have resided in, or travelled in a foreign country for at least 1 month:
Countries: ___________________________________
4) Do you have:
Recent contact with a person with acve tuberculosis? Yes No
Any condion that decreases your immune system? Yes No
An organ transplant? Yes No
5) Have you had any of the following acve TB symptoms for more than 3 weeks:
Coughing up blood
Yes No
Persistent coughing
Yes No
Excessive fague
Yes No
Excessive sweang at night
Yes No
Persistent fever
Yes No
Hoarseness
Yes No
Unexplained weight loss
Yes No
Occupaonal Health Only
QuanFERON Blood Draw: Date: ___________ Result: Negave Posive Indeterminate
Chest X-Ray: Date: ___________ Date Read: ___________ Result: ___________________________
Acon: ________________________________________________________________________________________
Reviewed By: _______________________________ Date: ___________
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Page 4 of 7
PRE-EMPLOYMENT DRUG TESTING HS 7309
Appendix A
CONSENT TO SUBSTANCE ABUSE SCREENING
I. I, , consent to submit a specimen of urine
or breath (alcohol suspicion based only) under the direcon of medical personnel of UCLA Health. I understand that this
specimen or sample will be used for the purpose of conducng a chemical analysis to determine if I have engaged in use
of alcohol or illegal drugs. I further give my permission to UCLA Health to release my screening results to any author-
ized Medical Review Ocer and to medical personnel in the UCLA Occupaonal Health Facility, but to no other person
without my further wrien consent. I understand that this examinaon is being conducted pursuant to UCLA Policy. I
will cooperate fully with UCLA Health and its designated tesng personnel in the administering of the drug and alcohol
screening.
II. I have I have not taken ANY medicaon and/or drugs of any kind in the past thirst (30) days including:
(check appropriate box)
Over-the-counter medicaons Prescripon or other drugs
III. Drugs that I have taken within the past thirty (30) days include (connue on separate sheet if necessary):
Brand Name of Drug
Dosage/Strength Per
Day
Date and Time of
Dosage
How Many Days
Was it Used
Comments/Explanaons _____________________________________________________________________________
I cerfy that that any urine and/or breath specimen or sample given by me belongs to me and is given solely for the
purposes of substance abuse screening. I further cerfy that the above informaon is correct to the best of my
knowledge. I understand that UCLA Health may require me to produce documentaon to verify the above informaon
and that my refusal to do so may result in disciplinary acon up to and including dismissal from employment.
In consideraon of my connued employment, I hereby release and agree to hold UCLA Health and its representaves
harmless against any and all claims, charges or causes of acon whatsoever I now have or may have in the future, which
may arise from this test. I understand that UCLA Health or any other laboratory selected by UCLA has the exclusive
control over the method of conducng this test.
I CERTIFY THAT I HAVE READ AND AGREE TO THE ABOVE PROVISIONS.
Employee Signature Date
Witness Signature Date
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OCCUPATIONAL HEALTH SERVICES
New Hire Immunizaon/Titer Requirements
Page 5 of 7
UCLA Health screens all new hires for Tuberculosis, Measles, Mumps, Rubella, Varicella and Hepatitis B immunity,
as recommended by the Center for Disease Control and Prevention.
Please bring a printed copy of your immunization records with documentation of the following to your health
screening appointment. If you are unable to provide documentation of these requirements, we will provide titers
during your visit, a follow-up appointment may be required if any vaccines or chest x-ray are needed for
clearance.
Measles, Mumps and Rubella Immunity
Medical of 2 MMR vaccinations at 28 days apart
blood titers indicating to Measles, Mumps and Rubella
Documented evidence of all three diseases
Varicella Immunity
Medical of 2 Varicella vaccinations at least 28 days apart
blood titers indicating to Varicella
evidence of disease
Screening
All employees will receive a QuantiFERON-TB Test or provide documentation of a negative QFT within a 3-month
window
If history of a positive TB screening test, please provide the following:
proof of a positive Gold blood test
TB screening is an annual requirement
Hepatitis B Screening
Proof of 3 Hepatitis B vaccinations
Proof of positive Hepatitis B surface blood titer immunity
Note that only completion of the 3 shot vaccine series plus a protective hepatitis surface antibody titer
collected not earlier than 1-2 months after the 3 shot series is completed is considered evidence of
protection against hepatitis B, so for the protection of healthcare personnel both are recommended.
Tetanus, Diphtheria, Pertussis Vaccine (Tdap)
Proof of Tdap vaccine. Healthcare personnel should have documentation of current Tdap on file.
Flu Vaccination
Please provide of seasonal flu vaccine. Flu vaccination will be available during pre-employment
screening generally late Sept - April. UCLA requires employees working in a clinical area to wear a mask if
declining immunization, in patient rooms or patient areas within 6 feet of patients during the flu season:
Nov.1 – March 31.
Page 6 of 7
Hepatitis B Vaccine
I understand that due to my occupaonal exposure to blood or other potenally infecous materials, I may be at risk of acquir-
ing hepas B virus (HBV) infecon.
(Please check appropriate box)
I would like to receive the hepas B vaccine.
Hepatitis B Vaccine Declination (mandatory)
I have been given the opportunity to be vaccinated with hepas B vaccine, at no charge to me; however, I decline
hepas B vaccinaon at this me. I understand that by declining this vaccine, I connue to be at risk of acquiring
hepas B, a serious disease.
I decline the hepas B vaccine series due to the following reason(s):
(Please mark at least one choice)
I have previously completed a hepas B 3-vaccine series with wrien documentaon and choose not to
repeat the vaccine series at this me.
I have previously completed a hepas B 3-vaccine series, but I do not have wrien documentaon and
choose not to repeat the vaccine series at this me.
I have been diagnosed with hepas B in the past.
Other: ___________________________________________________________________________
Signature Date Date of Birth
Print Name Job Title/Department
1/3/19
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Page 7 of 7
Tdap Vaccine
I understand that due to my occupaonal exposure aerosol transmissible diseases, I may be at risk of acquiring infecon
with Pertussis.
(Please check appropriate box)
I would like to receive the Tdap vaccine.
Tdap Vaccine Declination (mandatory)
I have been given the opportunity to be vaccinated against this disease or pathogen at no charge to me; however, I
decline the Tdap vaccinaon at this me. I understand that by declining this vaccine, I connue to be at risk of
acquiring Pertussis, a serious disease.
I decline the Pertussis vaccine due to the following reason(s):
(Please mark at least one choice)
I am declining because I choose not to have the Tdap vaccinaon.
I have already received a Tdap vaccinaon. I have a record or know the date and locaon of that vac-
cinaon.
I have already received a Tdap vaccinaon. I do not have a record or cannot recall when I received the
vaccinaon.
Other: ___________________________________________________________________________
Signature Date Date of Birth
Print Name Job Title/Department
1/3/19
UCLA ID number
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Completed 11 August 2021

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