UHHSP HEALTH SCREENING FORM

Instructions for Completing the Health Screening Form

Thank you for participating in our health screening process. To ensure accuracy and completeness, please follow these instructions carefully.

1. Completion by a Healthcare Provider:
- If you are visiting a healthcare provider to complete the health screening form, please provide them with a copy of the form for completion.
- Ensure that all sections of the form are filled out accurately, including personal information and medical history
- If opting for the virtual form, begin by providing an email address. The system will automatically email a copy of the completed form upon saving.
2. Two-Step TB Test:
- If you are required to undergo a two-step TB test, please follow these steps:
  For the first step: Your healthcare provider will administer the TB skin test and record the date.
- After 48-72 hours, return to your healthcare provider for the reading of the first step. Ensure that the date of the first reading is recorded on the form.
- Your healthcare provider will then schedule the second step of the TB test, typically 1-3 weeks after the first step.
- Upon returning for the second step, your provider will administer the TB skin test again and record the date.
- After another 48-72 hours, return to your healthcare provider for the reading of the second step. Ensure that the date of the second reading is recorded on the form.
- If completing the virtual form, you will need to access your active form when returning to the office for both the first and second readings.
- 3. Submission:
- Once the form is completed by your healthcare provider, ensure that all required fields are filled out.
- If completing the virtual form, review the information for accuracy before saving.
- Upon submission or saving, you will receive a confirmation email with a copy of the completed form for your records.
If you have any questions or encounter any issues while completing the form, please don't hesitate to contact our office for assistance.

Thank you for your cooperation in completing the health screening form.
Volunteer or Parent Email Address
example@example.com
Healthcare Provider Email Address
example@example.com

VOLUNTEER HEALTH SCREENING FORM
Volunteer Full Name*
Birthdate (MM/DD/YYYY)*

MonthDayYear
To be completed by your Health Care Provider. Please do not send immunization records. If not completed by your healthcare provider, this form will not be accepted

INFLUENZA VACCINATION INFORMATION
Please provide the date of the most recent influenza vaccination or attach proof of flu vaccine in the region below. Flu vaccines are only required annually if volunteering between the months of October through April.
Date Patient Received Flu Vaccination.

MonthDayYear
Leave blank if the not vaccinated
Attach proof of flu vaccine if date is not reported above

Cancelof

TUBERCULOSIS (TB) SCREENING RESULTS
Check only those to which the answer is YES:

I have been a temporary or permanent residence of 1 month in a country with a high TB rate (Any country other than the United States, Canada, Australia, New Zealand, and those in Northern Europe or Western Europe) since my last TB test.I am currently or will be immunosuppressed [this includes those with HIV infection, recipients of organ transplants, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone >15 mg/day for 1 month) or other immunosuppressive medication].I have been in close contact with someone who has had infectious TB disease since my last TB test.I currently have symptoms of TB (a cough lasting longer than three weeks, unexplained weight loss, night sweats or a fever.I will be volunteering more than 150 hours in a year with UHHS.
Please provide the date of your most recent tuberculosis screening, which should have been conducted within the last six months. If you are unsure of the date or if a two-step TB screening hasn't been performed within the last six months, a two-step TB screening is necessary.

If you answer 'yes' to any of the questions above or if you haven't had a TB screening within the last six months, one of the following tests is required. If either of these tests shows a positive result, you must also submit a provider clearance note confirming that the volunteer does not have an active TB infection, as demonstrated by a Chest X-ray.
Date of last TB screening: If test was not within the last 6 months, please complete a 2-step TB screening and report that date.

MonthDayYear
Date
TB Skin Test: Date of Read #1

MonthDayYear
Date
Read #1 Results (mm)
induration size in mm
TB Skin Test: Test Result of Read #1

PositiveNegative
TB Skin Test: Date of Read #2

MonthDayYear
Date
Read #2 Results (mm)
induration size in mm
TB Skin Test: Test Result of Read #1

PositiveNegative
Serum TB test (Quantiferon Gold, Tspot)

MonthDayYear
Date
Result

FOR THOSE VOLUNTEERING IN PEDIATRICS, NEWBORN & LABOR & DELIVERY UNITS
CHICKEN POX (one of the following is required):
- Two doses of varicella vaccine.
- History of disease.
- Date: Proof of immunity.
Date give: Dose #1

MonthDayYear
Date
Date give: Dose #2

MonthDayYear
Date
History of disease: Date of Diagnosis

MonthDayYear
Date
Proof of immunity: Titer date

MonthDayYear
Date
Result
MMR (one of the following is required):
- Two doses of MMR vaccine.
- Proof of immunity.
Date give: Dose #1

MonthDayYear
Date
Date give: Dose #2

MonthDayYear
Date
Proof of Immunity:Titer date

MonthDayYear
Date
Result
TDAP: Date Given

MonthDayYear
Date
HEPATITIS B (one of the following is required)
- Completion of a full vaccine series of Hepatitis B (2 or 3 vaccine series accepted)
- Proof of immunity.
Date given: Dose #1

MonthDayYear
Date
Date given: Dose #2

MonthDayYear
Date
Proof of immunity: Titer date

MonthDayYear
Date
Result
Healthcare Provider Confirmation: I confirm that I have reviewed that the information provided by the individual above is correct and I know of no medical reason this individual should not be allowed to volunteer at a UHHS facility.
Clinician name (Printed)
Clinician or Office phone number
Clinician or Office Address
Clinician signature

Clear
Should be Empty:

VOLUNTEER HEALTH SCREENING FORM