HCMC PREPLACEMENT HEALTH SCREENING FOR THE
ED RESEARCH ASSOCIATE PROGRAM
To ED Research Associate Program Applicants:
Congratulations on your admission to the Fall 2013 ED Research Associate Program. To claim your place, you must complete and return this
health screening packet by August 16th. Complete health screening packets should be mailed to:
ED Research Associate Program
Hennepin County Medical Center
701 Park Avenue – Mail Code R2
Minneapolis, MN 55415
The health screening packet includes:





Emergency Contact Information
Immunity Profile Requirements/Checklist (with attached documentation)
A Two-Step TB Test
Evaluation of Latex & Allergy Sensitivity Screening
Scent-Free Working Environment Acknowledgement
Last
Name:
Maiden/
Other name:
Street
Address:
First
Name:
Social Security
Number:
xxx-xx-
City:
Sex:
State:
 Male  Female
Middle
Name:
Zip:
Date
of Birth
Phone (
)
Place
of Birth
Places where you have lived or traveled outside USA:
Please list any allergies you have:
In Emergency Notify:
Phone (
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)
HCMC RA PROGRAM
IMMUNITY PROFILE REQUIREMENTS/CHECKLIST
The purpose of this questionnaire is to determine your immunity and infectious disease status. Please be sure all the information has
been completed and required documentation attached before submitting this form. All documentation will need to be reviewed before
you can start your volunteer program. This information will not be shared with your supervisor unless it has implications for work
restrictions or your safety.
**Be sure to check one statement for each test once you have the appropriate documentation.**
Applicant Name: (Print) ___________________________________________ DOB: __________________
1.
TB skin test:
___ I have attached documentation for 2 tuberculin skin tests that have been completed within the last year. (One needs to
have been done within the last 6 months.) This documentation can be provided by having your provider complete the Routine
TB Testing sheet included in this packet or provide their own professional documentation.
___ I have a history of a positive tuberculin skin test and have attached all the following information:
a. A copy of the results of a chest x-ray done within the last 2 years.
b. The completed Positive Mantoux Survey that is part of this packet.
2.
Rubeola (Measles) testing:
___ I have attached documentation of two doses of live vaccine that were given on or after my first birthday.
___ I have attached laboratory evidence of immunity. (Rubeola titer)
3.
Rubella testing:
___ I have attached documentation of one dose of live vaccine on or after my first birthday.
___ I have attached laboratory evidence of immunity.(Rubella titer)
4.
Mumps testing:
___ I have attached documentation of two doses of the live vaccine.
___ I have attached laboratory evidence of immunity. (Mumps titer)
5.
Varicella testing:
___ I have attached documentation of two Varicella vaccinations.
___ I have attached laboratory evidence of immunity. (Varicella titer)
___ I have attached written documentation from my doctor’s office indicating I have had the disease.
6.
Hepatitis B testing (Optional):
___ I have attached documentation of three Hepatitis B vaccinations.
___ I have attached laboratory evidence of immunity. ( Hepatitis B titer. )
***Please submit this information with your application. ***
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ROUTINE TUBERCULOSIS TESTING / FOLLOW-UP SCREENING
NAME:
______________________
To be completed by patients with:
To be completed by patients with:
History of NEGATIVE TST
History of POSITIVE TST
Or told by healthcare provider that they can no longer have a TB test.
PLEASE BRING THIS NOTICE to have a Mantoux placed.
Can be done at:
Primary MD, Community Clinic, School Health Service –
but must be done prior to application acceptance
POSITIVE MANTOUX SURVEY
***************************************************** Fill in the information below ONLY if you have a history of
Tuberculin Skin Test Number ONE (PPD 5 T.U. Intradermal)
positive TST and return this form to the RA program.
Date given:
 Aplisol  Sanofi  Other:
Lot #:
Site 
Right Forearm
In the past year have you had any of the following
symptoms for greater than 1-2 weeks:
 Left Forearm
 Other
Given by:
Clinic:
Must be read in 48 to 72 hours by your designated reader:
Self-reading is not acceptable.
TST Results:
Date Read:
Reading:
mm induration
Read by:
Cough?
 Yes  No
Cough or change in cough?
 Yes  No
Loss of appetite?
 Yes  No
Night sweats?
 Yes  No
Fatigue?
 Yes  No
In the last year have you ever had:
Bloody sputum?
 Yes  No
Exposure to TB?
 Yes  No
Clinic:
Tuberculin Skin Test Number TWO: (PPD 5 T.U. Intradermal)
Comments
Date given:
 Aplisol  Sanofi  Other:
Lot #:
Site 
Right Forearm
 Left Forearm
 Other
Given by:
Clinic:
Must be read in 48 to 72 hours by your designated reader:
Self-reading is not acceptable.
TST Results:
Date Read:
Reading:
Read by:
Clinic:
mm induration
Signature
EOHW LATEX SENSITIVITY SCREENING
Name__________________________________________ Job Class_ED Research Associate Volunteer_ Date ___________
Department_ED_____________________________ Number of years in occupation ______________________
PLEASE ANSWER THE FOLLOWING QUESTIONS:
Have you ever had eczema, rashes or itching on hands after wearing gloves?
Have you developed hives after wearing gloves or being exposed to latex?
Have you ever developed shortness of breath or wheezing after wearing gloves or being
exposed to latex?
Have you ever had throat swelling or an anaphylactic reaction related to latex?
Do your lips swell up or itch after blowing up a balloon?
Have you ever reacted to condoms or diaphragms? (swelling, pain, itching or hives)
Do you have reactions (swelling, itching, trouble breathing or swallowing or hives) during
dental procedures?
Are you allergic to any fruits or vegetables (banana, avocado, tropical fruits, kiwi, chestnuts,
tomatoes, potatoes & celery)?
Do you have a history of asthma?
YES
NO
**If you answered “yes” to any of the questions above, please complete the questions below**
IRRITANT CONTACT DERMATITIS ASSESSMENT (skin only)
Do you have rashes, itching, cracking, scaling or weeping of the skin from exposure to latex?
Have the above symptoms changed or worsened in the past year?
Have you tried a non-latex alternative?
If so, have you had the same or similar symptoms as with the latex product?
Do these symptoms persist when you stop all exposure to latex?
YES
NO
ALLERGIC CONTACT URTICARIA (HIVES) ASSESSMENT (skin only)
When you have contact with latex or are exposed to others wearing latex, do you get hives,
red itchy or swollen skin, or water blisters?
YES
NO
IMMUNE SYSTEM RESPONSE ASSESSMENT ** MD note needed**
When you have contact with latex, powdered latex gloves or are exposed to others wearing
latex, have you noticed any:
Itchy red eyes, fits of sneezing, runny nose or itching of the nose or mouth?
Shortness of breath, wheezing, chest tightness or difficulty breathing?
Other acute reactions including generalized or severe swelling or shock?
YES
NO
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A SCENT FREE HEALTH
CARE ENVIRONMENT
PATIENTS, VISITORS, AND EMPLOYEES MAY EXPERIENCE ADVERSE HEALTH REACTIONS DUE TO THE USE OF SCENTED PERSONAL AND
INDUSTRIAL PRODUCTS. WE MAY ASK YOU FOR YOUR UNDERSTANDING AND REQUEST THAT YOU WASH OFF A PERSONAL SCENT IF YOU
ARE WEARING ONE WHILE AT THE MEDICAL CENTER.
THANK YOU FOR YOUR COOPERATION AND FOR JOINING
US IN PROTECTING THE HEALTH OF OTHERS.
NAME:
DATE:
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