ledical Schoo! levark, NI 07101 RUTGERS furs ete rete Psrsara 08 New Je Mareh 2019 Dear Doctor: Welcome to Rutgers. For your protection, all Rutgers postgraduate physicians and dentists must have a preplacement medical evaluation by the NIMS Occupational Medicine Service (OMS) that includes: 1) A baseline Health Questionnaire. Please explain all “Yes” answers and specify the year you ‘Tdap in Question 43. 2) Documented proof of immunity by serologic testing for hepatitis B (HB surface antibody, HB core antibody and HB surface antigen), measles, mumps, rubella, and varicella. 3) A 2-stage tuberculosis skin test (TST) documented in mm induration, unless previously posi ‘© Ifanegative TST is documented in mm induration after July 1, 2018, only 1 additional TST is required. ‘This must be done by the OMS before starting work * Ifyou have a history of a positive TST, you must provide written documentation in mm induration. + Ifyou completed treatment for latent tuberculosis infection or active TB disease, you must provide written documentation. + Ifadequate written documentation of a positive TST is not available, a new TB skin test is required. «Ifyou are diagnosed with latent tuberculosis infection, ie, a positive TB surveillance test, you must have chest x-rays after April 1, 2019, and be evaluated for treatment if not previously treated. Enclosed, please find copies of the following: 1) Preplacement Health History Questionnaire (Required to complete and return). 2) Hepatitis B Vaccine Form (Required to complete and return), 3) House Officer Record of Health Status # A guide, not required to be completed and returned. ‘+ If used, completed by current healthcare provider with COPLES of exam resulis and proofs of immunity. ‘© Selfeported information, self-evaluations and evaluations by family member table. Itis highly recommended that you complete all requirements prior to orientation. If needed, all clinical tests can be obtained at the OMS without charge. Please call 973.972.2900 to make an appointment. ‘Alternatively, if you complete and return the enclosed health questionnaires prior to orientation, you can get the tests done at orientation. Respirator fit testing will be done at orientation or by Rutgers Environmental Health and Safety. If you get tested elsewhere, the OMS cannot reimburse you. To insure confidentiality, please send all medical information directly to the NIMS Occupational Medicine Service. We are located in the Stanley S. Bergen Jr. Building, 65 Bergen Street, Suite GA-167, ‘Newark, NJ 07107, telephone 973.972.2900, fax 973.972.2904 or email it to Bryan Bocco, APN, at bwb48@njms.rutgers.cdu. (Please do not mail the University policy back — we already have it.) ‘The complete Rutgers Policy on Housestaff Immunizations and Health Requirements (#40.3.2) is at hntpd/poliies.rutgers.edu/sites/polices/files/40,3.2%20-%420current.pdf If you have any questions about the medical evaluation, please contact Mr. Bocco or me at 973.972.2900. Thank you for your cooperation in completing this mandated evaluation Sincerely, . i" ow, & Bbw ace be Lawrence D. Budnick, MD, MPH. Director EnclosuresRUTGERS New Jersey Medical School ‘occupational Medicine Senice Rutgers, The 5 Bergen St Newark 572-2904 MEDICAL CONFIDENTIAL HEALTH QUESTIONNAIRE Name (please print): Last ist Mailing address: nee ‘Street City State Home telephone number: Cell telephone number: Email address: Social Security Number: Date of birth Birthplace: © American Indian/Alaskan Native CO Asian/Pacific Islander Race/Ethnicity Maiden or other previous names used: Middle eee Employee 1D Number: Age: Gender: [] Female (] Male 1] 1 Black, not Hispanic CO Hispanic white, not Hispanic O other Person to contact in emergency Relationship Emergeney telephone number: Have you ever been hospitalized or treated atthe University Hospital of Newark? Yes, Year___ 1] No Have you ever been seen for any reason atthe NIMS Occupational Medicine Service? C] Yes, Year__ [1] No Current employer: Position applied for:... School/Unit: 1cA Cinsms []som C)scs C)sup C)sn C) spn (]usxc (otter. Department Signature. Work location: Work tel no: Today's date: Forme. 1419NOYES RUTGERS New Jersey Medical School Cccupetiona! Medcne Service Employee Health History Last | Health History — Please EXPLAIN all YES answers ied a physician in the past year? ‘Absent from work or school for a medical reason inthe past year? Health worsened in the past year? Ever absent from work or school for an illness or injury related to work or due to a chemical or other hazard? ‘Wear prescription eyeglasses or contact lenses? Any visual difficulties that are not correctable? Use dentures? Cold or sore throat more than twice a year? Recurrent ear infections or perforated eardrum? 10, Difficulty hearing or an abnormal hearing test ever? 11. Allergic to medicine(s)? 12, Allergic to animal(s)? 13, Allergic to latex? 14, Hayfever, allergic to food or other substances in the environment? 15, Special diet for medical reasons? 16. Skin troubles? 17. Skin rashes or diseases that prevent you from shaving (for men) or interfere with wearing a respirator? 18, Any x-ray picture during the past year? 19. An abnormal chest x-ray ever? 20. Prescription medications over the past month? 21. Other medicines, including for colds, diet and headaches, vitamins, and eye and nose drops over the past month? 22. Hospital inpatient overnight? 23. Currently pregnant (for women)? IF NO, last menstrual period: 24, Served in military or uniformed services? 25. Any medical condition that requires you to restrict your activity? 26, Ever to change jobs or work assignments because of any health problem or injury? 227 Ever received compensation for any illness or injury resulting from work or military service? caaanaues|? ‘Communicable Diseases History ~ Please EXPLAIN all YES answers 28. Tuberculosis skin test (PPD) in the past 12 months? 29. Tuberculosis skin test (PPD) more than 12 months ago? 30. Positive or abnormal tuberculosis skin test ever? 31. Tuberculosis disease? 32. Told you need medicines for exposure to tuberculosis or for tuberculosis disease? 33. Immunized with the BCG (Bacille Calmette-Guerin) tuberculosis vaccine? 34. Lived or traveled outside the United States or Canada? 35. Close contact with a family member or other person who had tuberculosis? 36. Exposed to tuberculosis in a previous job? 37. Persistent cough, fever, night sweats, fatigue, chills, unexplained weight los, shortness of breath or chest pain? 38. Measles, mumps or rubella (German measles)? 39. Immunized with two (2) doses of measles, mumps and rubella (MMR) vaccine? 40. Chickenpox or varicella? 41. Immunized with two (2) doses of chickenpox or varicella vaccine? 42, Immunized for tetanus (tetanus shot) inthe past 10 years? 43, Immunized with the Tetanus, diphtheria and acellular pertussis (Tdap) vaceine since 2006? 44, Received a blood transfusion ever? 445, Exposed in a previous job to blood or body fluids that may have contained bloodbome pathogens, including hepatitis B virus, hepatitis C virus, or human immunodeficiency virus? 46, Hepatitis or jaundice? 47. Immunized with three (3) doses of hepatitis B vaccine? 48. Told you need medicines for meningitis or for exposure to meningit 49. Immunized with meningitis vacct 0, Immunized with influenza vac .?NO. Noncommunicable Diseases History - Please EXPLAIN all YES answers ‘I. Chest pain when you exert yourself, for example, when climbing stairs, walking or running? 52. Coronary artery disease or other heart disease? 53. Had a heart attack, coronary bypass surgery or any treatment for coronary artery disease? ‘4, Palpitations, rheumatic fever or heart murmur? '35. Blood pressure is greater than 150/90 with or without medication? '56. Quickly become short of breath when climbing stars or walking 57. Asthma? If yes, latest episode: '58. Chronic cough, other respiratory problem or chronic lung disease, for example, emphysema or bronchi ‘59. An abnormal lung function test ever? 60. Frequent or persistent stomach or other intestinal trouble? 61. Liver disease? (62, Hernia? 63. Back pain ever? If yes, latest episode: (64. Broken bone or dislocation? 65. Painful, swollen or stiff shoulder, arm, wrist, finger, leg, knee or foot? (66. Headaches that incapacitate you? 67. Seizure disorder or epilepsy, paralysis or history of fainting or being unconscious? 68, Claustrophobia? 69. Difficulty reading or learning disabil 70. Kidney or bladder trouble or blood in your urine? 71, Diabetes mellitus? 72. Weight change in the past year? 73, Treated for a cyst, growth, tumor or cancer? 74, Immune suppression or deficiency? 75, Amputation? 76. Any surgical operation? ‘Other Exposures History - Please DISCUSS all YES answers 7. Smoke cigarettes currently? 78. Smoked cigarettes ever? 79. Used other tobacco products ever? 80, Drink alcohol, including beer, wine or other liquor? 81. If you drink alcohol, ever attempted to cut down on your drinking, annoyed by other people criticizing your drinking, felt guilty about drinking or taken a morning eye-opener? 82. Injured in a road traffic crash, fight or assault? 83. Worked with anesthetic gases, anticancer agents, ethylene oxide, formaldehyde or glutaraldehyde? 84, Worked with hazardous waste, benzene, carbon tetrachloride, irritant dusts, isocyanates, paints, pesticides, ‘petroleum products, phenol, silica, solvents, toluene or welding fumes? 85. Worked with chromium, lead, mereury, or other metals? 86. Worked with radioactive materials or radiation-producing machines? 87. Exposed to loud noise for over one month? £88. Worked in a hospital or other health care facility? £89. Worked with asbestos or in building construction, mining, pipefiting, plumbing, a chemi refinery or shipyard? 90. Exposed to chemical or other hazards not noted above? 91. Worked in other environments with materials that concer you? 92. Advised to wear personal protective equipment on a job? 93. Difficulty wearing latex gloves or other personal protective equipment? 94. Wom a respirator ever? 95. Medicaly restricted from using a respirator? 96. Any symptoms from exposure to chemical or other hazards? 97. Any hobby activities that expose you to dusts, chemicals or fumes? 98. Any other medical problems not noted above or other circumstances that should be reported to fairly complete these questions and determine medical factors for fitness for duty and job placement? 9, Please specify: Left-handed or Right-handed? | plant, foundry, certify that the above is accurate and true to the best of my knowledge. Date ‘eFormb23.13.17RUTGERS gee ese ey en (ee New Jersey Medical School in and Documentat Hepatitis B Vaccine Declina' Hepatitis B Vaccine Declination (OSHA Section 1910.1030, Appendix A, Mandatory) understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious ‘materials and I want to be vaccinated with hepatitis B vaccine, | can receive the vaccination series at no charge to me. Hepatitis B Vaccine Documentation, Ihave had fewer than the recommended 3 doses of hepatitis B vaccine previously. I will go to the Occupational Medicine Service to either begin or complete the hepatitis B vaccine series, as long as I do not have natural hepatitis B virus infection. Thad a previous series of 3 doses of hepatitis B vaccine in (specify year{s}) Signature Name (please print) Department Date FormiiBV3.12.865 Bergen Steet, Suite G16 New Jersey Medical School Nenatk NI G7 RUTGERS fee Te St nse New srsaraaa0e House Officer Record of Health Status - Incoming 2019 Name of House Officer (please print): Date of birt: Employee ID Number: A. Department: Title Please have the following form completed by your health eare provider. ‘Self-reported information, self-evaluations and evaluations by family members are not acceptable. Every house officer MUST complete a history form, provide proof of immunity (serologic test results) to hepatitis B (HB surface antibody, HB core antibody and HB surface antigen), measles, mumps, rubella and varicella, and have a 2-stage tuberculin skin test (TST) documented in mm induration (unless exempt). ‘© Ifa negative TST is documented in mm induration after July 1, 2018, only | additional TST is required. This rust be done by the NIMS OMS before starting work. Ifyou have a history of a positive TST, you must provide written documentation in_mm induration. If you completed treatment for latent tuberculosis infection or active TB disease, you must provide written documentation, Ifadequate documentation of a positive TST is not available, a new TTB skin testis required, Ifyou are diagnosed with latent tuberculosis infection, ie, a positive TB surveillance test, you must have chest x-rays afier April 1, 2019, and be evaluated for treatment if not previously treated. ‘© You must provide year of Tetanus, Diphtheria and Acellular Pertussis (Tdap) vaccination, Done Result Mandatory Tuberculosis Skin Test (acceptable if since July 1, 2018) mm ‘Chest x-rays (required if TST is positive) after April 1, 2019 sory Serologic Tests (copy of lab r it be attached! B Surface Antigen Hepatitis B Surface Antibody Hepatitis B Core Antibody Measles Mumps Rubella Varicella Hepatitis B (23 doses) MMR (2 doses) Polio Tdap Varicella (2 doses) tions Rect Signature of personal physician or health care provider Date Name Title housestafetterFeb 2019,