HealthCare Clearance Form

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Health Screening
Name: _________________________________________________________________Date: _______________
Directions: Please take this form to your health care provider/ Student Health Service for completion. Submit this completed
documentation with your Privileges/Credentialing application.
For Health Care Provider Completion:
For this individual to qualify to work, volunteer, or observe at the Brigham and Women’s Hospital, there are minimal
infection control standards that need to be met. A list of the standards is on the back of this form.
Please complete the form below with special consideration to the following:



If there is not evidence of measles, mumps, rubella, or varicella immunity, please administer vaccine or draw titer(s);
Please plant and read a TB skin test, if this applicant has not had one in the past year.
For applicants with a past positive TB skin test, please complete the section labeled “Symptom Review” and obtain a
chest x-ray which rules out active TB if one is not on file.
For questions on form completion, call 617-732-6034. Thank You.
TB Skin Test
(At least one within 12
months of start date)
Symptom Review
(Only for applicants
who have a history of
a positive PPD)
Chest X-ray is
required
Date Planted: ______
Date Read: _______
Result in mm: _______
Date Planted: ______
Date Read: _______
Result in mm: _______
Loss of appetite
Unexplained weight loss
Night Sweats
Chest X-Ray Date
LTBI Treatment Length
INH Completion Date
Td/Tdap
Td______________
Influenza Vaccine
Seasonal _____________
 Yes
 Yes
 Yes
 No
 No
 No
Fever
Fatigue
Productive Cough
 Yes
 Yes
 Yes



Tdap ______________
PLEASE NOTE: THE INFORMATION BELOW IS REQUIRED FOR NON-BWH EMPLOYEES ONLY
Titer Result
Date
Date
Date
(circle)
MMR #1
MMR #2
POS / NEG
MMR
Measles #1
Measles #2
POS / NEG
Measles
Mumps#1
Mumps #2
POS / NEG
Mumps
Rubella
POS / NEG
Rubella
Varivax #1
Varivax #2
POS / NEG
Varicella
Hep B #1
POS / NEG
Hepatitis B
Antibody Hepatitis B
Hep B #2
Hep B #3
Type Name Health Care Provider
Signature of Health Care Provider
Location
I HEREBY CERTIFY THAT ALL STATEMENTS ARE TRUE.
SIGNATURE OF APPLICANT
Date
Telephone
No
No
No
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