Professional Documents
Culture Documents
New Hire Medical Checklist 4.27.12
New Hire Medical Checklist 4.27.12
Revision20120427
Name:
Date:
PLEASEREADDIRECTIONSCAREFULLY.Thefollowinginformationneedstobeobtainedaspartofyour
requirementsforemployment.Pleaseprovideanyproofofimmunizationordocumentationinsupportofthe
informationbeingcollected.YouMUSTbringthiscompletedchecklistwithANY/ALLdocumentationforitems
requestedtoyourfirstweekoftraining.
HepatitisB:Thisisanoptionalvaccine.PleasecheckONLYONEboxbelow.ONLYSIGN/DATEBELOW
IFYOUCHECKTHENOBOX.
YESIwanttostarttheHepBseries.ThefirstshotintheHepBserieswillbeprovidedtoyou
duringthefirstweekoftraining.Youwillberequiredtoreceiveyour2ndand3rdinjectionsatthe
requiredintervalstocompletetheseries.(2ndshotat30daysand3rdshotat6months).Youwill
alsoberequiredtoprovidedocumentationtothetraininglabaseachshotiscompleted.
IhavereceivedtheHepBseriesdocumentationattached.
NOIdonotwanttogettheHepBvaccine.Ifyoucheckedthisbox,pleasesign/datebelowto
decline.
________________________________________________
Sign/Date
Measles,Mumps,Rubella(MMR):PleasecheckONLYONEboxbelow.
Ihavetwoshotsonrecorddocumentationattached.
Ihavealabreportofapositivetiterattached.
IdonothaveanyproofofimmunityforMMR.Youwillhaveyourblooddrawnwhileintraining.
Varicella(chickenpox):PleasecheckONLYONEboxbelow.
Ihavetwoshotsonrecorddocumentationattached.
Ihavealabreportofapositivetiterattached.
IdonothaveanyproofofimmunityforVaricella.Youwillhaveyourblooddrawnwhileintraining.
TB(PPD)test:PleasecheckONLYONEboxbelow.IfyouhaveEVERhadapositiveTBtest
youMUSTcheckthethirdboxandprovidewhatisrequested.
IhaveacurrentTBtest(withinthelastyear)documentationattached.
1
UnitedAllergyServicesConfidentialandProprietary
NewHireMedicalChecklist
Revision20120427
IDONOThaveacurrentTBtestaTBtestwillbeplacedwhileintraining.
IhavehadapositiveTBtestinthepastIhaveattachedproofofanegativechestxraydone
withinthelastyearand/ortreatmentplanfrommyphysician.
CPRtraining:AreyoucurrentinCPR(ifitexpireswithin3monthsoftraining,checkno)?
YESAttachacopyofthefrontandbackofyourSIGNEDCPRcard.
NOCPRwillbedoneduringyourfirstweekoftraining.
VaccineInformationStatements(VIS):
YesIhavereceived,readandunderstandtheHepatitisBandTuberculinSkinTestingVISthat
wereattachedwiththischecklist.SignANDdateonthelinebelow.
________________________________________________
Sign/Date
DONOTWRITEINTHISSECTIONFORTRAININGLABUSEONLY.
CLASSDATE:__________________________________
HepB:
Shot1:
Shot2:
Shot3:
PositiveTiter:
Needed
Complete
OR
Declined
N/A
N/A
N/A
N/A
MMR
Shot1:
Shot2:
N/A
PositiveTiter:
Varicella
Shot1:
Shot2:
N/A
PositiveTiter:
PPD
CurrentNeg
PPDplaced:
ResultofPPD
HistoryofpositivePPD.
test:
_____________ placed:________ Dateofnegchestxray:
________
____________
CPRcurrent
Yes
No
N/A
Cardreceived:
within3mos: Expdate:
YesExp.Date:__________
Initialdocumentationprovided Yes No
Recordsverified&transcribedabove Yes N/A
NewhirecompletedVISsectionwithsignature/date. Yes
ForwardedtoVitalLife:Date__________________Initials__________
FinalMedicalHistoryfromVitalLifeverifiedbyTraining/credentialingcoordinator.Allapplicable
informationtranscribedabove.Date__________________Initials__________
2
UnitedAllergyServicesConfidentialandProprietary
Hepatitis B Vaccine
Many Vaccine Information Statements are available in Spanish and other languages.
See www.immunize.org/vis.
Hojas de Informacin Sobre Vacunas estn disponibles en Espaol y en
muchos otros idiomas. Visite http://www.immunize.org/vis
What is hepatitis B?
Hepatitis B Vaccine
2/2/2012
42 U.S.C. 300aa-26
TB Blood Tests
What is an Interferon Gamma Release
Assay (IGRA)?
An IGRA is a blood test that can determine if a person
has been infected with TB bacteria. An IGRA measures
how strong a persons immune system reacts to TB
bacteria by testing the persons blood in a laboratory.
Two IGRAs are approved by the U.S. Food and Drug
Administration (FDA) and are available in the
United States:
1) QuantiFERON-TB Gold In-Tube test
(QFT-GIT)
2) T-SPOT.TB test (T-Spot)
Choosing a TB Test
Choosing which TB test to use should be done by the
persons health care provider. Factors in selecting which
test to use include the reason for testing, test availability,
and cost. Generally, it is not recommended to test a
person with both a TST and an IGRA.
Related Links
CDC. Tuberculosis (TB): http://www.cdc.gov/tb
Basic TB Information: http://www.cdc.gov/tb/
publications/factsheets/general/tb.htm
November 2011