Annual Employee Health Assessment

Annual Employee Health Assessment - Have you had a positive...

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Annual Employee Health Assessment Employee Name__________________________ Site________________ Date_________ Circle: Business Clinical In the past year 1 Have any medical conditions developed or changed that will interfere with the essential functions of your job? ________ No _________ Yes If you answered yes please explain ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ _____ 2 Have you developed any allergy to latex or other natural rubber products? _______ No ________ Yes If you answered yes please explain ___________________________________________ ___________________________________________ ______________________________ 3 Tuberculosis: Tuberculosis skin testing is required annually for all staff unless you have a history of a positive PPD or the disease.
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Unformatted text preview: Have you had a positive PPD in the past? ______ No ________ Yes Of you answered yes have you had any fever, weight loss, night sweats, cough (dry or productive), bloody sputum, or chest pain that lasted more than 5 days in the past year ____ No ________ Yes If you answered yes please explain any follow-up care you received ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________ Annual PPD Date Immunization Dose/route Site Exp date Lot # Nurse Results: _______ Negative ________ Positive Date read: _________ Read by: _________ I certify that the information on this form is complete and accurate to the best of my knowledge. Employee Signature ______________________ Date__________ Reviewed by_____________________________ Date __________...
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Annual Employee Health Assessment - Have you had a positive...

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