Pre-Employment/Pre-Service Health Assessment
The New York State Department of Health (DOH) and/or North Shore–LIJ Health System mandates that all persons
seeking employment and/or a appointment to the Medical Staff of a hospital in the North Shore-Long Island Jewish
Health System have a current physical and recorded medical history as well as documented immunity as outlined in
our infection control policy.
For your convenience you can elect to have all exams and tests performed by either your personal physician or
North Shore-LIJ Employee Health Services (EHS). To insure your safety and the safety of our patients, all of the
following requirements must been completed prior to employment or providing services.
Requirements include:
1.
Have a recent physical examination and recorded medical history
2.
Tuberculosis Screening:
 Two-step Tuberculin Skin Testing (TST/PPD) is required. This requirement may be satisfied by the
following processes
 EHS will perform two TSTs, one week apart.
 Provide documentation to EHS of a negative TST within the past 12 months. That test may be
utilized as the initial step in the two-step testing procedure. EHS will perform the second TST.
 Provide documentation to EHS of two negative TSTs performed within the past 12 months
Exception:
If documentation is provided with a recorded history of positive TST and a standard chest x-ray report
within the past year is provided.
3.
Proof of Viral Immunity: (vaccine can be administer to you in EHS if not previously done)
 Hepatitis B surface antigen and surface antibody results
 Rubella Titer
 Rubeola Titer
 Varicella Titer
 Mumps Titer
If Rubella, Rubeola or Varicella Titers are negative, documentation of vaccination is required unless
contraindicated. (Vaccination document should include the signature of the person who administered the
vaccine as well as the product and date administered.)
4.
Tetanus/Diphtheria or Tetanus/Diphtheria/Pertussis Vaccination
Exception: If documentation of immunization within the preceding ten years is provided
5.
Urine toxicology screening
6.
Color Vision testing (as required)
7.
Respiratory Fit Testing (as clinically required)
Required completed forms include:
1.
Pre-Employment/Pre-Service Health Assessment Form
2.
Medical Evaluation for Respirator Use
3.
Latex Allergy Screening
Please complete the forms prior to your Employee Health Services appointment and bring them with you.
Pre-Employment/Pre-Service Health Assessment
Today’s Date: ___________________
Part I: To be completed by Applicant.
Last Name: _______________________________ First Name: ___________________________ M. I.:_______
Date of Birth: __________________
Social Security #: ___________________ Email: ___________________
Address: _____________________________________________________________________________________
Street
City
State
Home Phone #: ______________________ Cell Phone #:_____________________
Zip
Sex:
Male
Female
Name of hospital(s) that you are applying to: ________________________________________________________
Position/Job Title: __________________________________________
Phone #: ____________________
Department: _______________________________________________
Division: ____________________
Emergency Notification: Name: ________________________________________________________________
Address: ________________________________________________________________
Phone #: ________________________________
Relationship: _________________
Personal Physician:
Name: _________________________________
Phone #: _____________________
HEALTH HISTORY– Check Yes or No. If Yes, please explain.
Do you have any medical conditions that we should be aware of in case of a medical emergency?
Yes
No
If Yes, please record here:
____________________________________________________________________________________________
____________________________________________________________________________________________
Do you take any medications?
Yes
No
If Yes, please record here:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
ILLNESS –Check Yes or No. If Yes, please explain and indicate year of occurrence.
Have you ever had or do you have now:
Any Skin Conditions___________________________
Yes
No
Seizure Disorder _________________________
Yes
No
Hearing Problems _____________________________
Yes
No
Diabetes _______________________________
Yes
No
Vision Problems(Glaucoma, cataracts, color blindness)
Yes
No
Night Sweats ___________________________
Yes
No
Difficulty Breathing ___________________________
Yes
No
Weight Loss ____________________________
Yes
No
Hernias _____________________________________
Yes
No
Cough _________________________________
Yes
No
Chronic or recurring pain or limited motion associated with: (describe)
Neck _______________________________________
Yes
No
Hand _________________________________
Yes
No
Arm ________________________________________
Yes
No
Wrist _________________________________
Yes
No
Back _______________________________________
Yes
No
Other_________________________________
Yes
No
ALLERGIES AND EXPOSURES – Check Yes or No. If Yes, please explain.
Have you ever had a reaction, allergy and/or sensitivity to any medications, food, LATEX, plants or
chemicals? If yes, please specify substance and reaction.
Yes
No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
COMMUNICABLE DISEASES
Tuberculosis: Have you ever had a positive Tuberculin Skin Test? If yes, please specify date of conversion
and periods of INH treatment.
Yes
No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Hepatitis: Have you been diagnosed with or exposed to Hepatitis B or C?
Yes
No
Initial Health Assessment Revised 3.14.07
Page 2 of 4
Pre-Employment/Pre-Service Health Assessment
Part II:
To be completed by examining practitioner:
Name: ___________________________________________ Date of Examination: _________________________
Age: __________ Height: __________ Weight: __________ Pulse: __________ Blood Pressure: _________
Normal
Abnormal
Please Specify:
HEENT
NECK
CHEST
HEART
ABD
EXT
NEURO
LYMPH
Tuberculosis:
For persons with a history of a negative TST, evidence of 2 negative TST’s within 12 months must be
documented:
TST Date: __________________________________________ Results:
Negative
Positive
TST Date: __________________________________________ Results:
Negative
Positive
For persons with a history of TST conversion, check all statements that apply:
Exposed to TB and converted TST in __________________ (date)
Never treated with INH
Treated with INH for _____________________ months
Symptom review:
Fever
Weight Loss
Night Sweats
Cough
Hemoptysis
None
Date of last Chest X-Ray:_____________ (Attach Results, must be in the past 12 months)
Hepatitis B:
Serologic Proof of Immunity Date: ________________________ (Attach Results)
Varicella:
Serologic Proof of Immunity Date: ________________________ (Attach Results)
OR
Vaccination Dates: (1) ___________________ (2) ______________________ (Attach documentation)
MMR:
Serologic Proof of immunity Date: ________________________ (Attach Results)
OR
Vaccination Dates: (1) ___________________ (2) ______________________ (Attach documentation)
Tetanus/Diphtheria or Tetanus/Diphtheria/Pertussis:
Date of last vaccination: _____________________ (must be within past 10 years)
To be Read and Signed by Examining Practitioner:
I have personally examined the above named employee/practitioner and find him/her free from any physical/emotional impairment which is a
potential risk to patients or which might interfere with the performance of employment and/or service duties, including the habituation or
addiction to depressants, stimulants, narcotics, alcohol or other substances.
Examining Practitioner’s Signature: ______________________________________________________________________________________
Print Name: ___________________________________________________________________________________ Date: _____/_____/_____
License #: __________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________
___________________________________________________________________________ Tel #: ___________________________
Initial Health Assessment Revised 3.14.07
Page 3 of 4
Pre-Employment/Pre-Service Health Assessment
To be Read and Signed by Applicant:
HEPATITIS B VACCINATION DECLINATION FORM
The Occupational Safety Health Administration (OSHA) regulations mandate implementation of protective measures against bloodborne
infectious diseases. The risk to health care workers who come into contact with blood and other body fluids can be significant. In an effort to
maintain a safe workplace, the hospital that you are applying to in North Shore-LIJ Health System will provide the vaccine to all individuals who
are employed and/or providing services. The vaccine shall be administered at no cost. In order to be in compliance, please read the following
statement and sign at the bottom.
I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at risk of acquiring Hepatitis B virus
(HBV) infections. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline
Hepatitis B vaccination at this time. I understand that my declining this vaccine, I continue to be at risk of acquiring Hepatits B, a serious
disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated
with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
__________________________________________/__________________________________________________ Date: _____/_____/_____
Signature
Print Name
To be Read and Signed by Applicant:
VARICELLA VACCINATION DECLINATION FORM
North Shore-LIJ Health System takes protective measures against such airborne infectious diseases as Varicella. The risk to health care workers
who come into contact with infected patients can be significant. In an effort to maintain a safe workplace, the hospital that you are applying to in
North Shore-LIJ Health System will provide the vaccine to all individuals who are employed and/or providing services. The vaccine shall be
administered at no cost. In order to be in compliance, please read the following statement and sign at the bottom.
I understand that due to my occupational exposure to varicella, I may be at risk for acquiring varicella. I have been given the opportunity to
receive the varicella vaccine. If I refuse the vaccine in the absence of medical contraindications, I understand that I may be ineligible for special
contagion pay if I am furloughed after an exposure. If in the future, I want to be vaccinated with the varicella vaccine, I can receive the vaccine
at no charge to me.
__________________________________________________________/___________________________________ Date: _____/_____/_____
Signature
Print Name
To be Read and Signed by Applicant:
I consent to a pre-employment/pre-service medical examination, collection of blood and/or urine, and administration of vaccination, as required
by _____________________________________________________, a Hospital in the North Shore-LIJ Health System, that I will be providing
services. The purpose of the examination is to insure that I am free from health impairment which might be of potential risk to patients and/or
personnel or which might interfere with the performance of my duties at the institution. I understand that this is a limited examination solely for
the purpose of determining fitness for employment and/or service. This exam does not purport to be a comprehensive medical examination.
I further understand that this medical examination will include a drug screen and that I will not be employed or be allowed to provide services if
this screen reveals the presence of an illegal drug, misuse/abuse of a controlled or other substances which might alter or impair my behavior
and/or ability to function.
I furthermore authorize the Employee Health Services of ______________________________________________ Hospital, its practitioners and
my private medical physician (if applicable) to release any and all information obtained in the pre-service medical examination to authorized
representatives of this hospital for the purpose of determining my fitness for duty and/or services. I understand that giving false or misleading
information or failure to disclose requested medial information will be grounds for denying my application or for dismissal. I certify that I have
disclosed all known current health conditions which might pose a risk to others or which might interfere with the performance of my duties. I
understand and the Hospital has agreed that it will not use or disclose any information obtained in my pre-service medical examination except for
the purposes set forth above or as required by law.
____________________________________________/_________________________________________________ Date: _____/_____/_____
Signature
Print Name
__________________________________________
EHS Reviewer Name
Cleared
Referred To:
Comments:
Initial Health Assessment Revised 3.14.07
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