Employee Health Assessment

Name(Required)

Last 4 of Social Security #(Required)

Email(Required)

Phone(Required)

TB Screening/Risk Assessment

Tuberculosis(Required)

Heart Disease(Required)

High Blood Pressure(Required)

Diabetes(Required)

Chickenpox/Varicella(Required)

Visual Impairment(Required)

Visual Impairment (corrected by glasses)(Required)

Hearing Impairment(Required)

Epilepsy or Seizure Disorder(Required)

Drug/Alcohol Abuse or Addiction(Required)

Psychiatric or Behavioral Disorder(Required)

Other

Have you ever been treated for a back injury?(Required)

If Yes, when(Required)

Do you have any sensitivity or allergy to latex products?(Required)

It is the employee’s responsibility to seek treatment of allergies or conditions, and to notify the Coordinator of any allergy/condition, which could potentially interfere or limit job performance. Have you ever received:

Workmen's compensation?(Required)

If Yes, when(Required)

Disability?(Required)

If Yes, when(Required)

Are you currently under the care of physician?(Required)

If Yes, please explain(Required)

List all prescription medications that you are currently taking(Required)

(Enter N/A if none)

TB Screening/Risk Assessment

1) Do you have a history of temporary or permanent residence (for >1 month) in a county with a high TB rate (i.e. any country other then Australia, Canada, New Zealand, The United States, and those in western or northern Europe)?(Required)

2) Do you have current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with ‎ an TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone>15mg/day for>1 month) or other immunosuppressive medication?(Required)

3) Have you had close contact with someone who has TB disease?(Required)

4) Have you ever been treated for latent TB infection?(Required)

5) Do you have any of the following symptoms: Productive cough for more then 3 weeks: Coughing up blood: unexplained weight loss: Fever, chills, or‎ drenching night sweats for no known reason: persistent shortness of breath: unexplained fatigue for more than 3 weeks: Chest pain?(Required)

6) Have you ever had a prior diagnosis of active TB, latent TB infection, a positive skin test, or positive blood test for TB?(Required)

7) Have you ever been treated with medication for TB or for a positive TB test?(Required)

Signed Name(Required)

Date(Required)

Untitled(Required)

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Name

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