Form Introductory Text
Employee Health Record
Please complete Section I of this form. A professional health examiner will complete section II when necessary.
1. Please select if you have experienced any of the following:
I certify that I am free from health impairment which is of potential risk to patients or which might interfere with the performance of my duties if employed. I certify that I am free from habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter my behavior. .
The New York State Health Department mandates that health care workers must have the following immunizations or tests for immunity. Please document administration of vaccines, response to screening tests, or documented history of test results.
If PPD is positive for the first time, then staff member must be evaluated for the need for treatment.
Is treatment for TB required?
Max number of files : 1
Max File Upload size of each file : 5 MB
Rubeola immunity must be demonstrated by all individuals born on or after January 1, 1957. Please check (√) and attach document:
Max File Upload size of each file : 1 MB
Hepatitis B Vaccine
I find no evidence of health impairment that would be of potential risk to patients or interfere in the performance of health care duties. I find no evidence of habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter this individual’s behavior.
