Corporate Health
Medical Center Co Service Bldg
2220 Circle Drive
111 00 Euclid Avenue
4th Floor/MCC0-6029
Cleveland, OH 44106
216 844 1453 Phone
216 844 3990 Fax
March, 2015
Dear Doctor:
Congratulations on your offer of employment at University Hospitals Case Medical Center (UHCMC). We hope
your experience here will be extremely positive and rewarding.
All University Hospitals Case Medical Center employees, including physicians, are required to have a postoffer/pre-employment health assessment. This will be done in the Corporate Health Service (CHS) at UHCMC. We
would like you to call as soon a possible to make an appointment for this assessment. We will attempt to
accommodate your schedule, but urge you to call for an appointment at your earliest convenience in advance of your
starting date.
YOU WILL NOT BE ABLE TO START ORIENTATION UNTIL THIS ASSESSMENT IS
COMPLETE.
In this packet you will find medical history forms which should be completed prior to your appointment and
brought with you to the Corporate Health Service on the day of your scheduled appointment. The
appointment will last approximately 30-45 minutes and will include reviewing your medical history, obtaining a
urine specimen for drug screening, placing a screening test for tuberculosis (PPD), and reviewing the need for any
other immunizations (i.e. diphtheria/tetanus/pertussis, hepatitis B vaccine etc,). We will ask you to have blood
drawn for titers (rubella, rubeola, mumps, varicella and hepatitis B if you had the vaccine). If you have any
records from previous blood tests, specifically titers as above, documentation of your immunizations, or chest
x-ray readings for those who are PPD positive, please bring those with you. We may not have to do further
testing if we can have written documentation.
For those individuals who will be working around lasers (i.e. Operating Suite, Dermatology) included is a form for
an eye examination, which you should schedule according to the directions on the form. The Corporate Health
Service will be responsible for paying for all of the above required services.
The Corporate Health Service is located on the 4th floor of the MCCO building. The hours are 7:30a.m. to 4:00p.m.,
Monday through Friday. The telephone number is 216-844-1602, and the FAX number is 216-844-3990.
At the time of your health assessment you will also be acquainted with the services offered through the Corporate
Health Service such as updating immunizations and the treatment of job-related illness and occupational injuries
such as needlestick injuries or splashes.
If you have any questions, please feel free to call for further information. We look forward to serving you and
working with you during your tenure at University Hospitals Case Medical Center.
Sincerely,
David M. Rosenberg, MD, MPH
Medical Director
Corporate Health Service
Ron Todaro, RN, COHN-S
Director, Corporate Health Service
CORPORATE HEALTH QUESTIONNAIRE
Name
Start Date_
Date
Date of birth
Male O
Job Title
Female O
Last 4 digits of SSN_
Department
Location
Do you have any medical condition or chronic symptoms which would interfere with your ability to perform your job duties?
No O
Yes O
If yes, please list:
History of: Hospitalization_
Surgery_
Heart Disease_
Hypertension
Stroke
Diabetes
Cancer/immune disease
Lung / respiratory_
Back / joint disease
Other
Do you take any prescription, over the counter or herbal medication?
No O
Yes O
If yes, please list:
Do you have allergies to medications, latex, food or other substances?
No O
Yes O
If yes, please list:
Have you had any work related injuries, chemical or body fluid exposures?
No
O
Yes O
If yes, describe:
Have you missed more than one week of work because of illness or injury?
No
O
Yes O
If yes, describe:
Do you use any products containing nicotine, including nicotine replacement therapy? No O Yes O
drinks / week
Do you drink alcohol No O
Yes O
Immunizations completed dates /year (OR copy of records)
Tdap (Tetanus/Dipth/Pertussis)
Influenza Vaccination
Hepatitis B series
Measles / Mumps /Rubella
Varicella
Tuberculosis history (PPD) Negative O
Positive
PPD
Chest
XRAY
Quantiferon/Tspot
INH treatment No O Yes O
Positive O
date
date
months
I certify that the above statements are true, complete and correct to the best of my knowledge and belief.
Signature
Date
FOR CORPORATE HEALTH USE ONLY
Blood Pressure
Pulse
Color vision screen
Asessment_
Plan
Comments
(
) HIRE PENDING TOXICOLOGY SCREEN
(
(
) PENDING FURTHER MEDICAL CLEARANCE
Reviewer
Employee health questionnaire 03/2012
Date
) TdaP Vaccine GIVEN TODAY
CORPORATE HEALTH
REGISTRATION
Date
Time
EMPLOYEE INFORMATION
Name - Last
Entity
Address
Social Security Number
First
Start Date
City
Middle Initial
F
Marital Status
Department
State
Zip
Phone
Have you ever been employed at UHC? If Yes - What Year?
Recruiter
M
Birthdate
Position
Nurse
Please complete all forms and bring them with you to Corporate Health on the day of your physical.
SP-2987 (4/11)
804902
CORPORATE HEALTH
REGISTRATION
Date
Time
EMPLOYEE INFORMATION
Name - Last
Entity
Address
Social Security Number
Recruiter
First
Start Date
City
Middle Initial
M
Marital Status
Department
State
Zip
Have you ever been employed at UHC? If Yes - What Year?
Phone
Position
Nurse
Please complete all forms and bring them with you to Corporate Health on the day of your physical.
SP-2987 (4/11)
804902
F
Birthdate
CORPORATE HEALTH SERVICES
TETANUS, DIPTHERIA, PERTUSSIS (Tdap) VACCINATION AND INFORMED CONSENT
Tdap vaccine is recommended by the Centers for Disease Control for health care workers to add protection against
pertussis and to replace a single dose of tetanus and diphtheria vaccine .Immunity against pertussis that we receive from
childhood vaccination begins to wear off by early adolescence .It is estimated that about 600,00 adults between the ages
of 19 – 64 contract pertussis each year and spread the infection .Infants and children are at the highest risk for
complications and fatalities from pertussis.
Tdap vaccine is offered as a single booster shot for healthcare workers over age 18 who have not received tetanus
pertussis vaccine..
WHO SHOULD NOT RECEIVE Tdap VACCINE
Previous vaccination with Tdap
Persons younger than 19.
Pregnant women and nursing mothers without a note from their primary care provider.
Serious allergic reaction to tetanus vaccine or Arthus reaction in the past
History of coma or seizure within 7 days following pertussis vaccine
History of epilepsy, Guillain Barre Syndrome, or other neurologic system disorders
History of severe local swelling or pain at the injection site after tetanus, diphtheria, or pertussis vaccine.
History of bleeding disorder, thrombocytopenia or on anticoagulant therapy
Current moderate or severe illness
POSSIBLE SIDE EFFECTS OF Tdap VACCINATION
Injection site pain, erythema, or swelling.
Headache, body aches, tiredness, and fever
Nausea, vomiting , diarrhea ,stomach ache.
Rare severe allergic reaction symptoms including difficulty breathing, hoarseness, wheezing, hives, weakness, fast heart
beat or dizziness.
EMPLOYEE MUST READ AND SIGN THIS SECTION
O UH EMPLOYEE
O OTHER
I have read the Vaccine Information Statement about Tdap vaccination and have been given the opportunity to
have my questions answered. I understand the severity of the diseases as explained, the benefits and risks of
Tdap vaccination , the contraindications and possible side effects to receiving the vaccine. As with all medical
treatment, there is no guarantee that I will become immune or that I will not experience an adverse effect from the
vaccine.
I consent to receive Tdap (Tetanus, Diptheria, Pertussis) vaccine
O
I decline to receive Tdap (Tetanus, Diptheria, Pertussis ) vaccine
O
Name (PRINT)
_DATE
Date of Birth
Last 4 digits SS#
XXX XX
Employee Signature
FOR CORPORATE HEALTH USE ONLY
Tetanus,Diptheria Pertussis VIS Edition -01/24/2012 Reviewed
Tdap Vaccine 0.5 ml injection R / L DELTOID IM Mfr Lot#
Given by
Tdap consent
Rev 01/2012
_Expir
DATE
University Case Medical Center
Cleveland Ohio
Phone 216 844 1602
Fax 216 844 3990
CORPORATE HEALTH
Tuberculosis Screen Form
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
Work in Hanna House
Bedford
Geauga
Home Care
⃞ UHMP/ MSO
⃞ RBC
⃞ Volunteer
⃞ UHMG
UHCMC
Conneaut
Geneva
Richmond
NAME:
Department
SSN:
Birthdate
⃞ Ahuja
⃞ Other
Title
Phone:
Signature:
Date:
Country of Birth:
Lived in U.S.A. How long?
Persistent cough, coughing up blood
Extreme fatigue, weakness
Unexplained night sweats
Unexplained weight loss, loss of appetite
Unexplained fever or chills
Have you received BCG vaccine-If born in another country
Have you ever had a positive TB skin test
Have you had medication for TB or a positive test
Submit a copy of chest x-ray report for positive PPD reactors
Date of positive PPD:
INH Therapy taken
_Length of treatment
Date of last CXR_
Quantiferon:
No
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
Yes
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
months
================================================================================================================
For Clinical Use Only –
Annual ⃞ First Step ⃞ Second Step ⃞ Exposure Follow-UP ⃞ Positive PPD History ⃞ Allergy History ⃞
Asymptomatic for tuberculosis
Testing ordered today:
No ⃞
Yes ⃞
Tuberculin Skin Test
STEP 1
Reviewed by_
⃞
Date:
0.1 ml PPD 5TU Intradermal Injection
PPD must be read in 48 to 72 hours
Administered by:
Left FA ⃞
Date PPD read:
Result:
Quantiferon
⃞
Right FA ⃞
mm Induration
Read by:
===============================================================================================================
STEP 2
Date:
0.1 ml PPD 5TU Intradermal Injection
PPD must be read in 48 to 72 hours
Administered by:
Left FA ⃞
Date PPD read:
Result:
Right FA ⃞
mm Induration
Read by:
REFER ANY INDURATION TO CORPORATE HEALTH FOR FURTHER EVALUATION
University Hospital Case Medical Center
216.844.1602 / Fax 216.844.3990
CREDENTIALED PROFESSIONALS
PLEASE FAX TO BERNICE TOLBERT RIGHT FAX (216)201-4682
MW:p-drive CorporatHealthTBScreenFrm(4)
Rev.01/2012
University Hospitals Case Medical Center
Guidelines for all Employees Working with Laser Equipment
TO:
Anesthesiology
Dermatology
Otolaryngology
Operative Services
Ophthalmology
Gynecology
Cardio-Thoracic Surgery
Urology
Card. Cath. Lab.
Gastroenterology
Plas. & Recon. Surgery
Clinical Eng.
FROM:
University Hospital Corporate Health Department
FAX: 216-844-3990
SUBJECT:
Eye Exams for those working with lasers
Radiation Oncology
General Surgery
Neuro Surgery
Employees of areas using laser technology who are in direct contact with the laser equipment must have
and eye examination prior to employment and at termination of their employment at University Hospitals Case
Medical Center (UHCMC). An appointment for the examination must be made before beginning to work with the
lasers.
Eye exams can be done at the Ophthalmology Practice office at UHCMC or at the satellite locations in Willoughby
and Beachwood. There are some evening and Saturday hour appointments at the satellites. The general telephone
number to make all appointments is 216-844-3601. There will be no charge to you for the visit.
EMPLOYEE NAME:
PAST EYE Hx
FAMILY EYE Hx
C.C.
PAST, CURRENT
EYE MEDS
VISUAL ACUITY
(CORRECTED) DIST.
BROWS, LIDS, LASHES
CONJUNCTIVA
CORNEA, SCLERA, IRIS,
PUPIL, LENS, (SLIT, LAMP)
INTRAOCULAR PRESSURE
(DILATED PUPIL) DISC
MACULA
VESSELS (Retinal)
MEDIA OPACITIES
FUNDUS PHOTOS
(ONLY IF DISC OR
RETINAL ABNORMALITY)
Last 4 digits of SS#
NORM OU
Neg.
Neg.
NONE
NONE
OD
OS
20/
20/
NORM OU
NORM OU
C/D
NORM OU
NORM OU
NORM OU
OD
DONE
DATE OF EXAM:
C/D
OS
DONE
EMPLOYEE HOSP. #
PHYSICIAN NAME
PHYSICIAN SIGNATURE
(Please Print)
(Please sign)
I authorize release of the information to University Hospital Corporate Health Department
Please fax form back to Corporate Health at 216-844-3990 or mail to MCCO 6029 - 4th Floor
EMPLOYEE SIGNATURE
DATE:
University Hospitals Corporate Health Department
Appendix C to Sec. 1910.134: OSHA Respirator
Medical Evaluation Questionnaire (Mandatory)
EMPLOYEE NAME:
EMPLOYER:
Last 4 digits of SS #:
To the employer:
Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.
To the employee:
Can you read (circle one): Yes / No
Your employer must allow you to answer this questionnaire during normal working
hours, or at a time and place that is convenient to you. To maintain your confidentiality, your
employer or supervisor must not look at or review your answers, and your employer must tell
you how to deliver or send this questionnaire to the health care professional who will review it.
Part A, Section 1. (Mandatory)
The following information must be provided by every employee who has been selected to
use any type of respirator (please print).
1. Today's date:
/
/
2. Your name:
3. Your age (to nearest year):
yrs.
4. Sex (circle one): Male / Female
5. Your height:
ft.
in. 6. Your weight:
lbs.
7. Your job title:
8. A phone number where you can be reached by the health care professional who reviews this
questionnaire (include the Area Code): (
)
9. The best time to phone you at this number:
A.M. / P.M.
10. Has your employer told you how to contact the health care professional who will review this
questionnaire (circle one): ........................................................................................Yes / No
11. Check the type of respirator you will use (you can check more than one category):
a.
N, R, or P disposable respirator (filter-mask, non-cartridge type only).
b.
Other type (please circle: half- or full-facepiece type, powered-air purifying,
supplied-air, self-contained breathing apparatus).
12. Have you worn a respirator previously (circle one): ................................................Yes / No
If ``yes,'' what type(s):
Part A. Section 2. (Mandatory)
Questions 1 through 9 below must be answered by every employee who has been selected to
use any type of respirator (please circle ``yes'' or ``no'').
1. Do you currently smoke, or have you smoked tobacco in the last month: ..................Yes / No
2. Have you ever had any of the following conditions?
a. Seizures (fits): ........................................................................................................Yes / No
b. Diabetes (sugar disease): .......................................................................................Yes / No
c. Allergic reactions that interfere with your breathing: ............................................Yes / No
d. Claustrophobia (fear of closed-in places): .............................................................Yes / No
e. Trouble smelling odors: .........................................................................................Yes / No
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University Hospitals Corporate Health Department
3. Have you ever had any of the following pulmonary or lung problems?
a. Asbestosis: .............................................................................................................Yes / No
b. Asthma ...................................................................................................................Yes / No
c. Chronic bronchitis:.................................................................................................Yes / No
d. Emphysema:...........................................................................................................Yes / No
e. Pneumonia:.............................................................................................................Yes / No
f. Tuberculosis: ..........................................................................................................Yes / No
g. Silicosis: .................................................................................................................Yes / No
h. Pneumothorax (collapsed lung): ............................................................................Yes / No
i. Lung cancer: ...........................................................................................................Yes / No
j. Broken ribs: ............................................................................................................Yes / No
k. Any chest injuries / surgeries:................................................................................Yes / No
l. Any other lung problem:.........................................................................................Yes / No
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
a. Shortness of breath:................................................................................................Yes / No
b. Shortness of breath walking fast on level ground or up a slight hill: ....................Yes / No
c. Shortness of breath walking at an ordinary pace on level ground: ........................Yes / No
d. Have to stop for breath when walking at your own pace on level ground: ...........Yes / No
e. Shortness of breath when washing or dressing yourself: .......................................Yes / No
f. Shortness of breath that interferes with your job: ..................................................Yes / No
g. Coughing that produces phlegm (thick sputum):...................................................Yes / No
h. Coughing that wakes you early in the morning: ....................................................Yes / No
i. Coughing that occurs mostly when you are lying down: .......................................Yes / No
j. Coughing up blood in the last month:.....................................................................Yes / No
k. Wheezing: ..............................................................................................................Yes / No
l. Wheezing that interferes with your job: .................................................................Yes / No
m. Chest pain when you breathe deeply: ...................................................................Yes / No
n. Any other symptoms that you think may be related to lung problems: .................Yes / No
5. Have you ever had any of the following cardiovascular or heart problems?
a. Heart attack: ...........................................................................................................Yes / No
b. Stroke: ....................................................................................................................Yes / No
c. Angina: ...................................................................................................................Yes / No
d. Heart failure: ..........................................................................................................Yes / No
e. Swelling in your legs or feet (not caused by walking):..........................................Yes / No
f. Heart arrhythmia (heart beating irregularly): .........................................................Yes / No
g. High blood pressure: ..............................................................................................Yes / No
h. Any other heart problem that you've been told about:...........................................Yes / No
6. Have you ever had any of the following cardiovascular or heart symptoms?
a. Frequent pain or tightness in your chest: ...............................................................Yes / No
b. Pain or tightness in your chest during physical activity: .......................................Yes / No
c. Pain or tightness in your chest that interferes with your job: ................................Yes / No
d. In the past two years, have you noticed your heart skipping/missing a beat:........Yes / No
e. Heartburn or indigestion that is not related to eating:............................................Yes / No
f. Other symptoms that may be related to heart or circulation problems: .................Yes / No
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7. Do you currently take medication for any of the following problems?
a. Breathing or lung problems: ..................................................................................Yes / No
b. Heart trouble: .........................................................................................................Yes / No
c. Blood pressure: ......................................................................................................Yes / No
d. Seizures (fits): ........................................................................................................Yes / No
8. If you've used a respirator, have you ever had any of the following problems? (If you've never
used a respirator, check the following space and go to question 9 .................................
.
a. Eye irritation: .........................................................................................................Yes / No
b. Skin allergies or rashes: .........................................................................................Yes / No
c. Anxiety:..................................................................................................................Yes / No
d. General weakness or fatigue: .................................................................................Yes / No
e. Any other problem that interferes with your use of a respirator:...........................Yes / No
9. Would you like to talk to the health care professional who will review this questionnaire about
your answers to this questionnaire:............................................................................Yes / No
Questions 10 to 15 below must be answered by every employee who has been selected to use
either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees
who have been selected to use other types of respirators, answering these questions is voluntary,
but will assist greatly in determining your ability to wear any type of respirator.
10. Have you ever lost vision in either eye (temporarily or permanently): .....................Yes / No
11. Do you currently have any of the following vision problems?
a. Wear contact lenses:...............................................................................................Yes / No
b. Wear glasses: .........................................................................................................Yes / No
c. Color blind: ............................................................................................................Yes / No
e. Other eye or vision problem: .................................................................................Yes / No
12. Have you ever had an injury to your ears, including a broken ear drum:..................Yes / No
13. Do you currently have any of the following hearing problems?
a. Difficulty hearing: ..................................................................................................Yes / No
b. Wear a hearing aid: ................................................................................................Yes / No
c. Other hearing or ear problem: ................................................................................Yes / No
14. Have you ever had a back injury: ..............................................................................Yes / No
15. Do you currently have any of the following musculoskeletal problems?
a. Weakness in any of your arms, hands, legs, or feet: ..............................................Yes / No
b. Back pain: ..............................................................................................................Yes / No
c. Difficulty fully moving your arms and legs:..........................................................Yes / No
d. Pain or stiffness when you lean forward or backward at the waist: ......................Yes / No
e. Difficulty fully moving your head up or down: .....................................................Yes / No
f. Difficulty fully moving your head side to side:......................................................Yes / No
g. Difficulty bending at your knees: ..........................................................................Yes / No
h. Difficulty squatting to the ground:.........................................................................Yes / No
i. Climbing a flight of stairs or a ladder carrying more than 25 lbs:..........................Yes / No
j. Any other muscle or skeletal problem that interferes with using a respirator: .......Yes / No
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University Hospitals Corporate Health Department
Would you like a copy of the report which will be given to your employer based upon this
questionaire and other testing .......................................................................................... Yes / No
I certify that all of the above answers are true and correct. I understand that any false statement may be cause for dismissal. I also understand that
any false statements may lead to an inaccurate evaluation of my ability to wear a respirator, and may result in my experiencing serious injury or
death. I willingly submit to all tests necessary to complete this examination, and I authorize the release of all information and results of the
examination to the above named employer.
Applicant Signature
Date
DO NOT WRITE BELOW THIS LINE
--------------------------------------------------------------------------------------------------------------------Reviewers comments
Reviewers Signature
M.D. D.O. PA-C NP RN Date
1.
In the past hour:
Smoked cigarette? ................ Yes / No
Used inhaler? ....................... Yes / No
Had a heavy meal? ............... Yes / No
2.
In the past 3 weeks:
Pneumonia / flu / bronchitis?
3.
In the past 6 months:
Abdominal surgery?............. Yes / No
Eye surgery: ......................... Yes / No
4.
Resting pulse > 100? ................................................... Yes / No
5.
BP> 169/103? ............................................................. Yes / No
6.
If any Yes answers, postpone testing.
Yes / No
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Department of Corporate Health
MCCO Building
Department of Corporate Health Medical
Center Company Services Building
“MCCO”- 2220 Circle Drive, 4th Floor
From Euclid Avenue:
Take Cornell Rd South
Turn Right onto Circle Drive
MCCO building is on the Right.
You will see a set of double glass doors with the red UH logo; take elevator to the 4th floor.
If parking on campus, Park in the Adelbert Road parking garage. Exit on the 1st floor through
the back of the garage.