OUTSIDE CLEARANCE FORM
SERVICES ARE TO BE DONE BY YOUR PCP (PRIMARY CARE PHYSICIAN)
NOT EMPLOYEE HEALTH SERVICES
HEALTH CLEARANCE VERIFICATION FOR: OBSERVERS/VISITING PROFESSORS/MISC
EMPLOYEE NAME:
DEPARTMENT LOCATION:
PHONE NUMBER:
DEPT CONTACT NAME & PHONE:
************************************************************************************
IMMUNIZATION DOCUMENTATION FOR INFECTIOUS DISEASE CLEARANCE IS AS FOLLOWS:
TB SCREENING – WILL ACCEPT 1 PPD WITHIN 365 DAYS, and a 2nd PPD WITHIN 90 DAYS
OR A QUANTIFERON TEST WITHIN 90 DAYS OF START DATE.
MANDATORY 2 STEP TUBERCULIN INTERMEDIATE SKIN TEST (PPD) OR QUANTIFERON
DATE PLACED:
DATE READ RESULTS: ____ MM INDURATION
NEG
POS
DATE PLACED:
DATE READ RESULTS: ____ MM INDURATION
NEG
POS
QUANTIFERON DATE:
RESULTS:
DATE OF ANNUAL TB SYMPTOM INTERVIEW:
HISTORY OF A BCG VACCINATION:
YES
NEG
POS
NO
(BCG IS A VACCINE GIVEN TO THOSE BORN OUTSIDE THE UNITED STATES.)
HISTORY OF POSITIVE PPD OR QUANTIFERON TEST: A CHEST X-RAY IS REQUIRED WITHIN 3
MONTHS OF ARRIVAL
CHEST X-RAY DATE:
HISTORY OF TREATMENT:
RESULTS:
YES
TB SYMPTOMS:
NO IF YES, DATE:
NEG
POS
HOW MANY MONTHS TAKEN:
**MANDATORY 2 IMMUNIZATION DATES OR + POSITIVE TITER REQUIRED:
**MMR (MEASLES; MUMPS; RUBELLA): VACCINE DATES: 1.
2.
OR
IF GIVEN SEPARATELY:
**RUBELLA VACCINE DATES:
1.
2.
OR TITER DATE:
RESULTS:
**RUBEOLA VACCINE DATES:
1.
2.
OR TITER DATE:
RESULTS:
**MUMPS VACCINE DATES:
1.
2.
OR TITER DATE:
RESULTS:
2.
OR TITER DATE:
RESULTS:
**VARICELLA: VACCINE DATES: 1.
DIRECT PATIENT CARE CONTACT REQUIRES:
HEPATITIS B SURFACE ANTIBODY (HBSAB) DATE:
NUMERIC VALUE RESULTS:
HEPATITIS C ANTIBODY TITER DATE:
RESULTS:
COLOR VISION TEST: NORMAL
ABNORMAL
mIU/ml
.
THIS EMPLOYEE HAS BEEN EDUCATED ON MODE OF TRANSMISSION, EXPOSURE, PREVENTION, REPORTING AND FOLLOW-UP FOR: AIRBORNE
PATHOGENS
BLOODBORNE PATHOGENS
(TO BE PROVIDED BY DEPARTMENT – HOSPITAL POLICY 2001, 2002, 2010, 2011, 2150, 2164 AND 2167 FOR REVIEW)
DO YOU HAVE HEALTH INSURANCE?
YES
NO - DO YOU HAVE A LOCAL PCP?
YES
NO
I HAVE EVALUATED THIS EMPLOYEE AND HAVE FOUND HER/HIM TO BE FREE FROM INFECTIOUS DISEASE.
PRIMARY CARE PHYSICIAN SIGNATURE:
DATE:
DEPARTMENT TO RETAIN ORIGINAL
S:\HBC\EmpHlth\OUTSIDE CLEARANCE FORM REV:1-15-15