IMPORTANT! As of 2023, please navigate to our updated form at:
AHC Occupational Health New Hire Health Assessment

 

Please do not proceed on this page as your submission will not be received. Please use the link above.

Preparing for your Occupational Health Visit

Step 1: Start Here

Complete the online health assessment before your scheduled on-boarding appointment.

Step 2: Plan Ahead & Fly Through Your Appointment

Bring the following documents with you to your appointment:

• Two Government issued photo ID

• Vaccination records and/or Lab Titers
  • COVID-19 vaccination required
  • Hepatitis B  (up to 6 documented vaccination doses)
  • Measles, Mumps Rubella (2 documented doses)
  • Varicella (2 documented doses)
  • Influenza (Current Season) 
  • Tdap (within 10 years) 
• Pharmacists, Pharmacy Techs, Oncology RN & Environmental Services Employees: Complete Blood Count (CBC), Complete Metabolic Panel and Urinalysis (within the last 6 months).

 
Requirements for Tuberculosis (TB) Documentation:

• QuantiFERON-TB Gold (QFT), T-Spot or two step TB Skin Test (TST) within 30 days of your start date
• Clear chest X-Ray for a history of a postive PPD, QuantiFERON or T-Spot
• Any prior TB documentation

Step 3: Under the Care of a Physician?

You may be required to provide a note from your physician stating your diagnosis, treatment, medications & restrictions. The note should state your condition is well managed & does not interfere with your ability to perform job responsibilities.

Step 4: Important Reminders for Your Appointment

Review the information below to receive your clearance in a timely manner.

• AHC has a no facial hair policy, please shave your face for N-95 Fit Testing
• COVID-19 vaccination is required for employment. If you have not completed your vaccination series, you will have a COVID-19 test.
• Do not fast. Eat and drink normally before your appointment
• If you wear glasses or contacts, bring them to your appointment
•  You will undergo a urine drug screen during the appointment. Make sure you are adequately hydrated. We are a tobacco & marijuana free workplace.

During your appointment we will review your health assessment, documentation, complete a physical, and fit you for an N-95 mask. If you are unable to provide documentation of vaccination(s) and/or labs, they will be completed at the time of your appointment. Failure to provide thorough documentation may result in onboarding delays.

By signing, I certify to having received & reviewed Adventist HealthCare's Notice of Privacy Practices, and I both understand & consent to the terms outlined in said policy.

IMPORTANT NOTE: A “Yes” responses in the above Health History sections are assumed to be stable and under the management of a healthcare professional OR conditions that have since resolved. If your condition is not well managed, please specify so in the comments and note that you will be required to follow up with your primary care provider (PCP) for clearance prior to Orientation.

I hereby certify the above answers to be true and correct to the best of my knowledge. I understand and agree that misrepresentation, falsification, or omission of facts may be cause for immediate dismissal without further recourse or appeal. I also understand that I must complete all requirements within the first week to be able to attend new employee orientation as per Employee Conduct Policy 2.20 and Pre-Employment Testing Policy 2.166 (see below).

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 healthcare professional who will review it.

Any “Yes” response requires medical follow-up; however, by signing below, you are attesting your condition is stable and/or well-managed by a primary care provider.

Subject:      Pre-Commencement Drug Testing

Purpose:     To ensure a drug-free workplace in accordance with the Federal Drug- Free Workplace Act of 1988

Policy:        Adventist HealthCare will not hire anyone who is known to be currently abusing drugs. To help ensure this, after a job offer has been made, a drug test will be done on the physical exam date, thus helping to ensure a safe environment for hospital employees, patients, and the general public.

1.   Applicants will be notified of the testing procedure via the employment form, flyers/postings displayed in the Human Resources office and during job interviews.

2.   A consent form will be obtained from the potential employee, outlining applicable procedures, and the possible consequences of positive results and refusal to take the test.

3.   Substances test for will include, but not be limited to: amphetamines, methadone, PCP, benzodiazepines, cocaine, opiates, barbiturates, cannabinoids and ecstasy. AHC will test for cotinine, a nicotine by-product to promote a tobacco free workplace.  AHC retains the right to test for other drugs.

4.   A body fluid specimen (urine/blood/saliva) will be obtained in the Employee Health Clinic on the date of your physical.  Refusal to consent to drug testing will result in the denial of employment.

5.   Specimens will be obtained in such a way as to maintain the individuals’ dignity and privacy while also ensuring the best possibility that the specimen is legitimate.

6.   In order to further ensure the security of the specimen, the employee will initial a tamper proof seal and immediately place it on the specimen container, in accordance with the chain of custody procedure.  The specimen will then be sent to a NIDA certified lab selected by the Hospital.

7.   Results of the test will be confidential and made available only on a “need to know” basis within the Hospital.  If results are positive, the individual will be offered the opportunity to have the same specimen re-tested at a credential lab.  The individual will also be given the opportunity to determine whether positive test results might be due to reasons other than drug abuse.  Confirmed positive results indicating unlawful drug use or tobacco use will result in the denial of employment at Adventist HealthCare.

8.   If a potential employee is denied employment due to positive drug results or because of refusal to take the test, they will be given the opportunity to reapply after a waiting period of one (1) year.  Those testing positive for cotinine are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine/cotinine products in the past ninety (90) days and successfully pass follow-up testing. Managers and supervisors will only be informed that the person was not able to pass the physical at this time.

9.   Employees are subject to testing for cause as provided in the Substance Abuse Policy.

I have been given the opportunity to read the drug testing policy and ask any questions that I might have regarding testing.

I agree to submit a urine/blood/saliva sample for the purpose of pre-employment drug testing analysis.  I further understand that the test results will be reported to AHC by a National Institution for Drug Abuse (NIDA) approved lab, following review by a Medical Review Officer.

I understand that, in the event of a positive test result, I will be contacted by a Medical Review Officer who will allow me an opportunity to provide a medical explanation for the positive test.  I will also have an opportunity to have the original sample re-tested. Test results will then be kept confidential in accordance with applicable law.

I have been given the opportunity to read the purpose, policy and procedure for this testing.  I understand that I will be denied employment if test results are positive. I further understand that the refusal to consent to drug testing will result in denial of employment.

I hereby release AHC, its employees, officers, directors, the testing laboratory and the individual(s) administering any such test from any liability whatsoever arising from the administration of any test and/or based upon the results of any such tests.

I acknowledge and understand that it is an express condition of my employment with AHC that I must sign this Consent Form and Release of Liability and undergo testing. I hereby consent to submit to a drug and/or alcohol test and cotinine testing in accordance with AHC policy.

I further understand that I will have a cotinine test, a nicotine by-product, to ensure a tobacco free workplace.  Those testing positive for cotinine are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine/cotinine products in the past ninety (90) days and successfully pass follow-up testing.  The results of this test will be made available to the Human Resources Department.

This occupational health examination is being conducted to determine your fitness for the job. Its purpose is to protect Adventist HealthCare's patients and employees from infectious diseases or other conditions, which would adversely affect them. This is not intended to be a comprehensive health assessment and should not take the place of, or be constructed to be, an annual physical evaluation that would normally be conducted by your personal healthcare provider.

HOLD HARMLESS CLAUSE:

"By my signature below, I understand that the health assessment to be performed upon me is not intended to be a comprehensive examination for general medical purposes but is only an examination for employment-related purposes to detect employment-related conditions. I agree to hold harmless Adventist HealthCare, Inc., its agents, and employees from any and all liability for any action or omission beyond the scope of this examination."

I understand that this occupational examination is requested and paid for by my employer. Furthermore, I understand that my employer requires a copy of the Physical Exam and testing above as a condition of clearance to begin employment or continued employment as part of the recertification process.

Per CDC guidelines and AHC policy, all healthcare personnel should complete this TB symptom screening questionnaire at the time of hite (pre-placement) and annually in their hire month. Occupational Health will reach out to you if further follow up is needed.

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NOTE: If your Hepatitis B titer is low, your job profile may still require you to receive the Hepatitis B vaccine series. Signing the declination form now may not exempt you from the vaccine series if your job profile requires immunization against Hepatitis B virus. You can discuss this during your occupational health onboarding appointment.

HEPATITIS B: Hepatitis B is a viral infection of the liver caused by Hepatitis B virus (HBV). About 1.25 million people in the U.S. have chronic Hepatitis B virus infection. Each year approximately 300,000 new infections are reported to the Center for Disease Control. Most people who become infected with Hepatitis B recover completely, but 5 to 10% will become chronic carriers of the virus. Although many chronic carriers do not have symptoms of the disease, they can transmit the virus to other persons, primarily through blood exposures. Each year 4,000 to 5,000 persons die from chronic Hepatitis B.

OCCUPATIONAL EXPOSURE: In the hospital, health care workers with direct patient contact, laboratory workers and researchers with blood or body fluid contact are at increased risk for acquiring the Hepatitis B virus. An unvaccinated individual who receives an accidental blood or body fluid exposure from an infected source has a 40% chance of becoming infected with Hepatitis B. Each year in the U.S., more than 9,000 health care workers contract Hepatitis B, and of those, 300 will die of liver-related disease.

VACCINATION: Becoming infected with Hepatitis B is preventable. The CDC recommends the Hepatitis B vaccine for all healthcare workers. Full immunization requires completion of a series of three vaccinations given over a six-month period. Around 80% to 90% of healthy people who receive the vaccine develop antibodies that protect them from getting Hepatitis B. There is no evidence that the vaccine has ever caused Hepatitis B. At this time, it is not clear if immunocompromised persons or if persons on dialysis might require additional doses of vaccine. The incidence of side effects is very low. A few people experience tenderness and redness at the injection site. A low-grade fever may occur. Rash, nausea, joint pain, and mild fatigue have also been reported.

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HPV) infection. I have been given the recommendation to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis 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 through AHC Occupational Health with no charge to me.